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(12) INTERNATIONAL APPLICATION PUBLISHED UNDER THE PATENT COOPERATION TREATY (PCT)

(19) World Intellectual Property
Organization

International Bureau

(43) International Publication Date
18 August 2005 (18.08.2005)

PCT

(10) International Publication Number

WO 2005/074373 A2

(51) International Patent Classification: Not classified

(21) International Application Number:

PCT7IL2005/000142

(22) International Filing Date: 4 February 2005 (04.02.2005)

(25) Filing Language:

(26) Publication Language:

English

(30) Priority Data:

60/542,022
60/566,078
60/566,079
60/604,615
60/633,428
60/633,442
60/633,429

5 February 2004
29 April 2004
29 April 2004
25 August 2004
7 December 2004
7 December 2004
7 December 2004

(05.02
(29.04.
(29.04.
(25.08.
(07.12.
(07.12.
(07.12.

2004)
2004)
2004)
2004)
2004)
2004)
2004)

US
US
US

us
us
us
us

(71) Applicant (for all designated States except US): RE-
ABILITY INC. [GB/GB]; Nerine Chambers, P.O. Box
905, Road Town, Tortola (VG).

(72) Inventors; and

(75) Inventors/Applicants (for US only): EINAV, Omer
[IL/IL]; 42875 Kfar Monash (IL). EINAV, Haim [IL/IL];
28 SHLUSH STREET, 65149 TEL-AVIV (IL). ROUSSO,
Benny [IL/IL]; 12 HENRY BERGSON STREET, 75801
RISHON LEZION (IL). SHABANOV, Doron [IL/IL];
34 HADKALIM BOULEVARD, 44862 ZUR IGAL
(IL). KATZIR, Eran [IL/IL]; 12 AMNON VETAMAR
STREET, 48580 ROSH HA'AYIN (IL). BINYAMINI,
Gad [IL/IL]; 45870 MOSHAV HAGOR (IL).

(74) Agents: FENSTER, Paul et aL; FENSTER & COM-
PANY, INTELLECTUAL PROPERTY LTD., P. O. BOX
10256, 49002 PETACH TIKVA (IL).

(81) Designated States (unless otherwise indicated, for every
kind of national protection available): AE, AG, AL, AM,

[ Continued on next page ]

(54) Title: METHODS AND APPARATUS FOR REHABILITATION AND TRAINING

1980

1988

1986

(57) Abstract: A method of rehabilitation using an ac-
tuator type that includes a movement mechanism capable
of applying a force that interacts with a motion of a pa-
tient's limb in a volume of at least 30 cm in diameter, in
at least three degrees of freedom of motion of the actuator
and capable of preventing substantial motion in any point
in any direction in said volume, comprising: exercising a
patient at a first place of rehabilitation selected from a bed,
a wheel-chair, a clinic and a home, using an actuator of said
actuator type which interacts with a motion of said patient;
and second exercising said patient at a second place of re-
habilitation selected from a bed, a wheel-chair, a clinic and
a home using a second actuator of said actuator type which
interacts with a motion of said patient; wherein said first
exercising and said second exercising utilize a same move-
ment mechanism design for moving the actuators.

WO 2005/074373 A2 I Mil llllllll II 111 111 Hill Hill II I II III Hill Hill II 111 Hill 111 lllllll llll III llll

AT, AU, AZ, BA, BB, BG, BR, BW, BY, BZ, CA, CH, CN,
CO, CR, CU, CZ, DE, DK, DM, DZ, EC, EE, EG, ES, FI,
GB, GD, GE, GH, GM, HR, HU, ID, IL, IN, IS, JP, KE,
KG, KP, KR, KZ, LC, LK, LR, LS, LT, LU, LV, MA, MD,
MG, MK, MN, MW, MX, MZ, NA, NI, NO, NZ, OM, PG,
PH, PL, PT, RO, RU, SC, SD, SE, SG, SK, SL, SY, TJ, TM,
TN, TR, TT, TZ, UA, UG, US, UZ, VC, VN, YU, ZA, ZM,
ZW.

(84) Designated States ( unless otherwise indicated, for every
kind of regional protection available)'. ARIPO (BW, GH,
GM, KE, LS, MW, MZ, NA, SD, SL, SZ, TZ, UG, ZM,
ZW), Eurasian (AM, AZ, BY, KG, KZ, MD, RU, TJ, TM),

European (AT, BE, BG, CH, CY, CZ, DE, DK, EE, ES, FI,
FR, GB, GR, HU, IE, IS, IT, LT, LU, MC, NL, PL, PT, RO,
SE, SI, SK, TR), OAPI (BF, BJ, CF, CG, CI, CM, GA, GN,
GQ, GW, ML, MR, NE, SN, TD, TG).

Published:

— without international search report and to be republished
upon receipt of that report

For two -letter codes and other abbreviations, refer to the "Guid-
ance Notes on Codes and Abbreviations" appearing at the begin-
ning of each regular issue of the PCT Gazette.

WO 2005/074373 PCT/IL2005/000142

METHODS AND APPARATUS FOR REHABILITATION AND TRAINING

RELATED APPLICATIONS

This application claims the benefit under 119(e) of U.S. Provisional
Application No. 60/542,022 filed on February 5, 2004, U.S. Provisional Application No.
5 60/566,078 filed on April 29, 2004, U.S. Provisional Application No. 60/566,079 filed on
April 29, 2004, U.S. Provisional Application No. 60/604,615 filed on August 25, 2004, U.S.
Provisional Application No. 60/633,428 filed on December 7, 2004, U.S. Provisional
Application No. 60/633,429 filed on December 7, 2004 and U.S. Provisional Application No.
60/633,442 filed on December 7, 2004 the disclosures of which are incorporated herein by
10 reference.

This application is also related to PCT applications, being filed on same date and by the
same applicant as the present application, entitled "Gait Rehabilitation Methods and
Apparatuses"; "Rehabilitation with Music"; "Neuromuscular Stimulation"; "Fine Motor
Control Rehabilitation"; "Methods and Apparatuses for Rehabilitation Exercise and Training";
15 "Methods and Apparatus for Rehabilitation and Training"; "Methods and Apparatus for
Rehabilitation and Training"; and having attorney docket numbers, 414/04391; 414/04396;
414/04400; 414/04401; 414/04388; 414/04404; and 414/04405 respectively. The disclosures
of all these applications are incorporated herein by reference.

FIELD OF THE INVENTION
20 The present invention relates to manipulation of a body, for example for physical

rehabilitation and/or training.

BACKGROUND OF THE INVENTION
After accidents or strokes, persons often need a prolonged rehabilitation process in an
attempt to recapture some or all of the body function damaged in the accident or stroke. Such
25 rehabilitation may include one or both of two elements, a physical rehabilitation portion, in
which damaged or unused muscles, nerves and/or joints are brought back to full functioning
(to the extent possible) and a cognitive rehabilitation portion, in which the cognitive ability to
control the body is restored. In some cases, the damage to the body and/or brain is such that a
patient needs to be trained in modified functionality (e.g., when one limb is made short) or
30 even new functionality, for example, in the use of an artificial limb.

Physical therapy is currently provided mainly by personal attention of a physical
therapist who monitors and instructs a patient in the performance of certain exercises. Thus,
costs for rehabilitation are high and compliance after a patient leaves a treatment center is

WO 2005/074373 PCT/IL2005/000142

relatively low.

Some home physical therapy devices are known, for example a product called
"backlife" provides CPM (Continuous Passive Motion) of the spine.

US patent 5,836,304, the disclosure of which is incorporated herein by reference,
5 describes a cognitive rehabilitation utilizing a remote therapist.

US patent 5,466,213, the disclosure of which is incorporated herein by reference,
describes a rehabilitation system using a robotic arm.

An article in Journal of Rehabilitation Research and Development, Vol. 37 No. 6,
November/December 2000, titled "Development of robots for rehabilitation therapy: The Palo
10 Alto VA/Stanford experience", by Charles G. Burgar, MD; Peter S. Lum, PhD; Peggy C. Shor,
OTR; H.F. Machiel Van der Loos, PhD, the disclosure of which is incorporated herein by
reference, describes usage of robots for rehabilitation.

SUMMARY OF THE INVENTION
A broad aspect of some embodiments of the invention relates to rehabilitation methods
15 and apparatus suitable for a wide range of situations, including, temporal, mental, cognitive,
motor, location and/or other situations.

An aspect of some embodiments of the invention relates to a rehabilitation device
which guides a patient to perform a motion with a correct spatial trajectory, by the device
applying one or more pushing, assisting, reminding, responding and/or resisting forces during
20 a motion (or intent to move) by the patient. In an exemplary embodiment of the invention, the
forces are applied by an actuator, for example, a robotic articulated arm or a spherically jointed
lever. In some embodiments, the applied forces act as a force field, optionally continuous,
which impedes and/or guides a patient. Alternatively or additionally to spatial trajectories,
orientation trajectories and/or speed trajectories are guided, supported and/or measured.
25 In an exemplary embodiment of the invention, the device supports, for a given volume

of space and a range of force strengths, substantially any 3D trajectory within that volume. In
an exemplary embodiment of the invention, a device is provided which supports the range of
motion of a healthy arm or leg in one, two or three dimensions. In some cases, a partial volume
is sufficient, for example, 50% or 30% of such a volume.
30 Optionally, the device is programmable with various trajectories (paths and/or

velocities) and/or forces. Optionally, the forces at one point in the trajectory can vary
responsive to an actual trajectory by the patient, possibly a same trajectory (e.g., at an earlier
point thereof) and/or responsive to a rehabilitation plan and/or improvement of the patient.

WO 2005/074373 PCT/IL2005/000142

Optionally, the device learns the patient motion and repeats it with a correction (e.g. a
smoothing of trajectory and or speed). Alternatively or additionally, the device can learn a
motion entered by a physiotherapist and replay it for the patient, with an optional adjustment
(e.g. a limb size adjustment).
5 In an exemplary embodiment of the invention, the trajectories and/or forces are defined

for one or more points on the body, on same and/or different limb or body part. Optionally, a
point is controlled (and/or measured) with 3, 4, 5 or 6 degrees of freedom.

In an exemplary embodiment of the invention, the programming comprises
programming an electronic controller. In an exemplary embodiment of the invention, the
1 0 programming comprises mechanical programming.

An aspect of some embodiments of the invention relates to a rehabilitation device
adapted for home use. In an exemplary embodiment of the invention, the device is portable in
a home, for example, not permanently attached to any surface and/or including wheels. In an
exemplary embodiment of the invention, the device is collapsible on a regular basis. In an
15 exemplary embodiment of the invention, the device is light enough to avoid structural
overloading of residential floors, for example the device can weigh less than 100kg, less than
50 Kg or less than 25Kg. Optionally, the device can be folded down to fit in a trunk of a
standard sedan-type car, for example having a maximum dimension of less than 120 cm.
Optionally, the device breaks down into parts which are light enough to be carried by a non-
20 handicapped person.

In an exemplary embodiment of the invention, the device ensures that a patient is
correctly positioned. Optionally, the patient is notified to correct his position. In an alternative
embodiment of the invention, the device recalibrates itself to take the patient position into
account.

25 In an exemplary embodiment of the invention, a device is usable (e.g., by

programming, attachments and/or setting) for a plurality of different treatments, for example, a
plurality of different body sizes, a plurality of different ages, a plurality of different joints
and/or a plurality of different appendages.

In an exemplary embodiment of the invention, a rehabilitation device is provided
30 which is portable for various activities, for example, indoors and/or outdoors, such as,
cooking, barbequing and eating at a table.

An aspect of some embodiments of the invention relates to rehabilitation of daily
activities, for example, eating, pouring tea, knocking nails and cooking. In an exemplary

WO 2005/074373 PCT/IL2005/000142

embodiment of the invention, a kit including position sensors and/or other sensors is provided
to attach to daily objects and track their use and provide feedback and/or instructions for
rehabilitation. Optionally, such feedback and/or guidance are provided mechanically by a
rehabilitation robot. In an exemplary embodiment of the invention, a daily activities training
5 pedestal includes one or more adjustable work spaces on which daily activities is carried out,
for example one surface emulating a table and another emulating a saucer (e.g., for training of
tea pouring.

An aspect of some embodiments of the invention relates to long term rehabilitation
and/or training. In an exemplary embodiment of the invention, a rehabilitation device is used

10 for a long period of time, for example, months or years. Optionally, a same device is used both
for rehabilitation and for training of a patient in correct motions. In an exemplary embodiment
of the invention, a rehabilitation device is used for preventive training, for example, ensuring
that a patient with developing arthritis does not start favoring a diseased joint. Optionally, a
rehabilitation device is used to achieve a specific rehabilitation goal, such as rehabilitation of a

15 particular limb. Optionally, the device is used for non-medical training, for example as a
universal gym machine.

An aspect of some embodiments of the invention relates to support and/or
measurement of various mental states of a patient, for example, motivation, depression,
endurance, ability to train in pain, ability and/or desire to communicate and/or work and/or

20 interact with others. These states often overlap. For example, depression is often expressed as
lack of motivation. In an exemplary embodiment of the invention, motivation is estimated by
comparing performance in diagnosis, game and/or therapy situations. Such comparing
optionally includes analyzing if a person achieved a same performance under different
motivational states and/or how often did the person strain his limits. In an exemplary

25 embodiment of the invention, the motivational state is used for one or more of estimating
progress, suggesting psychological treatment, controlling difficulty of exercise and/or
providing motivational incentives automatically.

An aspect of some embodiments of the invention relates to support and/or overcoming
of cognitive problems while performing physical rehabilitation. In an exemplary embodiment

30 of the invention, cognitive and/or perceptive limitations are overcome by providing one or
more of instructions, feedback and guidance in a plurality of modalities, in less damaged
modalities (e.g., selecting from various possibilities), and/or with a degree of enhancement
congruent with the limitation (e.g., larger letters for weak eyesight). In an exemplary

WO 2005/074373 PCT/IL2005/000142

embodiment of the invention, the degree of enhancement is changed over time, as part of a
rehabilitation of the limited function.

An aspect of some embodiments of the invention relates to multi-modal rehabilitation.
In an exemplary embodiment of the invention, multiple body systems (e.g., motor, visual,
5 auditory, visual-motor), skills and/or senses are rehabilitated using a same system, for
example, motor control, motor propreception, visual perception and sound generation. In an
exemplary embodiment of the invention, coordination between such systems is trained. In one
example, hand-eye coordination is rehabilitated. In another example, hand-leg coordination is
rehabilitated. In an exemplary embodiment of the invention, paths of coordination which are

1 0 damaged are targeted for rehabilitation.

An aspect of some embodiments of the invention relates to feedback for rehabilitation.
In an exemplary embodiment of the invention, the feedback includes feedback on carrying out
of daily activities. Alternatively or additionally, the feedback includes feedback from a remote
therapist or automatic feedback, during an activity. Alternatively or additionally, the feedback

1 5 includes on a quality of the motion carried out by the patient.

An aspect of some embodiments of the invention relates to rehabilitation treatment
methods. In an exemplary embodiment of the invention, training specifically in daily activities
is carried out with the assistance of a rehabilitation device. Alternatively or additionally,
training to prevent deterioration is provided, for example, to prevent deterioration of

20 Parkinson's disease caused by neglecting of arm/function. Alternatively or additionally,
training to provide long term improvement is carried out, for example, to provide improvement
in cerebral palsy. Alternatively or additionally, treatment to prevent disease is carried out, for
example, training a patient to not neglect a joint just because it hurts.

An aspect of some embodiments of the invention relates to using a rehabilitation device

25 for both rehabilitation and testing, diagnosing and/or monitoring. In an exemplary embodiment
of the invention, the device is used to assess the abilities of a patient and then to rehabilitate
that patient. Alternatively or additionally, the device is used to measure the patient and
calibrate future rehabilitation to those measurements. Exemplary measurements include size,
strength, range of motion and motion quality, mental state and/or cognitive and/or perceptive

30 abilities.

An aspect of some embodiments of the invention relates to a rehabilitation method
related to motion quality. In an exemplary embodiment of the invention, a quality of a motion
is defined. Optionally, when a patient is being rehabilitated, automated feedback is provided to

WO 2005/074373 PCT/IL2005/000142

the patient regarding the quality of his motion. Alternatively or additionally, part of
rehabilitation and/or training is teaching a patient the quality value for various motions.

An aspect of some embodiments of the invention relates to correctness of motion. In an
exemplary embodiment of the invention, a rehabilitation device is programmed with a correct
5 movement. In an exemplary embodiment of the invention, a correct motion is programmed
into the device by performing the correct motion and then storing the motion in a device-
associated memory. Optionally, the motion is programmed in during a dedicated teaching
mode or when the device is off-line. Alternatively, the device learns during usage by a patient.
Optionally, the device is used to teach a patient what correct motion is, for example
10 using template and/or using rules (e.g., a 2/3 power rule for motor control). In an exemplary
embodiment of the invention, correctness of motion is evaluated as a parameter of
rehabilitation and feedback is provided thereon.

An aspect of some embodiments of the invention relates to a rehabilitation device for
daily activities, in which the rehabilitation device is configured to train and/or test patients in
15 the carrying out of daily activities. In an exemplary embodiment of the invention, the
rehabilitation device can be used in proximity to real-life settings, such as a table or a counter.

An aspect of some embodiments of the invention relates to positioning of a
rehabilitation device including a motion mechanism. In an exemplary embodiment of the
invention, a motion mechanism has a limited range of motion and/or accuracy. The
20 rehabilitation device is optionally positioned to make maximum usage of this range of motion,
e.g., by matching to a specific exercise. In an exemplary embodiment of the invention, the
rehabilitation device includes a positioning element, for example a rail and/or one or more
joints that can be used to fix the motion mechanism at a desired position and/or orientation.
Optionally, the positioning element is motorized, for example, to allow automatic or non-
25 manual motion of the motion mechanism.

An aspect of some embodiments of the invention relates to a rehabilitation method in
which a healthy body part is used for rehabilitating a diseased body part. In an exemplary
embodiment of the invention, a rehabilitation device allows simultaneous or parallel motion of
two limbs, one damaged and one not, and uses the correct motion of an undamaged limb as a
30 basis for force field definition for the damaged limb. Alternatively or additionally, sequential
motion by undamaged and then damaged limbs is provided. Optionally, the undamaged motion
is modified, for example reduced in force, speed or range of motion. Optionally, the motion is
mirror motion or synchronized motion (e.g., arm and leg during swimming). In an exemplary

WO 2005/074373 PCT/IL2005/000142

embodiment of the invention, a device which can hold two limbs is used. In some
embodiments the motion of the two limbs is linked. In other embodiments, there is some or
complete de-coupling between the limbs, at least in real time.

An aspect of some embodiments of the invention relates to a multi-point rehabilitation
5 device in which the rehabilitation device is attached to a human body at multiple points which
can move relative to each other, which motion is part of rehabilitation.

In an exemplary embodiment of the invention, the rehabilitation device attaches to two
limbs, for example an arm and a leg or two arms.

In an exemplary embodiment of the invention, the rehabilitation device separately
10 allows motion in 3D space of two bones on either side of a joint.

In an exemplary embodiment of the invention, the device mechanically limits motion
for one or more of the points. Optionally, one or more of the points are tracked (in one or more
dimensions) but their motion is not mechanically limited in some or any directions.

In an exemplary embodiment of the invention, the rehabilitation device supports
15 complex motion in which different parts of the body are called upon to carry out certain
motions, for example, shoulder motion and wrist motion.

An aspect of some embodiments of the invention relates to a mechanical structure for a
rehabilitation device. In an exemplary embodiment of the invention, the device comprises an
arm mounted on a joint, with a body attachment point, for attachment to or holding by a
20 patient, mounted on the arm. The joint acts as a spherical joint, allowing movement of the arm
along substantially any path on the surface of a sphere, within a range of angles, for example,
±90 degrees relative to the center of the joint, in either of phi and theta directions (e.g., in
spherical coordinates). Optionally, the center of rotation for such motions is substantially a
same center of rotation for all the paths. In an exemplary embodiment of the invention, the
25 joint and/or the arm as a whole lack singularity points in the range of motion. Optionally, the
resistance to motion of the joint (the device may add resistance) is substantially uniform,
substantially independently of the spherical motion.

In an exemplary embodiment of the invention, the spherical joint comprises a ball in
socket joint, with the arm attached to the ball or to the socket. The other one of the ball or
30 socket is optionally attached to a base, for example, a base which stands on a floor or is
attached to a wall or a ceiling.

In an exemplary embodiment of the invention, balancing is provided. In one example,
the device includes a weight attached to said ball opposite of said arm and serving to balance

WO 2005/074373 PCT/IL2005/000142

the motion of said arm. Optionally, the motion of the arm is substantially balanced over the
entire range of motion thereof. In an exemplary embodiment of the invention, the balancing
includes prevention of a resting torque. Alternatively or additionally, balancing includes
correction for an existing moment of inertia or an expected moment of inertia during use.
5 Optionally, the device is configured to include a resting force which tends to stabilize or
destabilize the device, depending on the embodiment.

Optionally, one or more guiding plates are provided. In an exemplary embodiment of
the invention, a pin attached to the ball, optionally part of the weight, is constrained to travel
within a slot (e.g., a rectangle or other shape) defined in a guide plate. Optionally, the slot is
10 elastic.

Optionally, one or more motors are provided to rotate the ball and/or apply force in a
desired direction.

Optionally, one or more directional brakes are provided to selectively stop motion of
the ball in a desired direction.
1 5 Optionally, one or more uni-directional brakes are provided to selectively stop motion

of the ball in any direction.

In an alternatively embodiment of the invention, two or more joints having a shared
center of rotation, are provided instead of a ball, for example a universal joint.

In an exemplary embodiment of the invention, the arm is extendible along its axis.
20 Optionally, a motor is provided for selectively moving or apply force to resist motion of the
extension along the axis. Optionally, one or more brakes are provided to selectively resist
motion of said extension along said axis.

In an exemplary embodiment of the invention, the extension is balanced, so that it has
no self motion. Alternatively or additionally, the extension, even when extended to various
25 extents does not affect a balance of said arm.

Optionally, a rehabilitation device is positionable at various orientations. Optionally,
the device includes a joint between its base and an articulating portion thereof.

An aspect of some embodiments of the invention relates to a ball joint with selective
locking. In an exemplary embodiment of the invention, a chuck is provided to selectively lock
30 rotation of the ball joint. Optionally, a plurality of directional brakes are provided. Optionally,
one or more sensors generates an indication of a direction of force application and a controller
selects which directional and/or uni-directional brakes to release responsive to the force
direction.

WO 2005/074373 PCT/IL2005/000142

An aspect of some embodiments of the invention relates to a telescoping element,
optionally used as part of a rehabilitation device. In an exemplary embodiment of the
invention, at least three portions are provided, two ends and a center, with extension or
retraction forces being applied to the central portion. The central portion is attached to the two
5 end portions using a rack and pinion (one rack on each end portion and the two pinions at
either end of the central portion. A belt interconnects the two pinions so that they move in
concert.

An aspect of some embodiments of the invention relates to a force-feedback control
mechanism including a spring. Changes in compliance are provided by changing an effective
10 length of the spring. In an exemplary embodiment of the invention, the spring is a flat spiral
spring and the compliance is in a direction perpendicular to the plane of the spring.

An aspect of some embodiments of the invention relates to a force control mechanism
for a human-movable element. In an exemplary embodiment of the invention, a spring is
provided to counteract force applied by a human. Optionally, the degree of force is adjustable,
1 5 optionally by preloading the spring (or other resilient element). Optionally, the human movable
element is also moved by a motor and said compliance is optionally provided to said human
motion. Optionally a damping element, for example viscous cushioning, is provided.

In an exemplary embodiment of the invention, the resilient element is configurable,
optionally on the fly, to provide a desired degree of resistance to the movement. Optionally,
20 the resilient means is re-adjusted to follow actual motion of the element.

In an exemplary embodiment of the invention, the motor moves the handle using one
joint and a second joint is used for the force compliance.

In an exemplary embodiment of the invention, the force compliance is provided by one
resilient element to a plurality of axes simultaneously, substantially without coupling between
25 the axes.

In an exemplary embodiment of the invention, movement of the element in spherical
rotation axially compresses a resilient element which then provides compliance.

In an exemplary embodiment of the invention, power is provided to the element using a
gear system which cannot be back-driven. When back-driving is detected, it is mechanically
30 shunted to a resilient element, which provides compliance.

In an exemplary embodiment of the invention, a mechanical diode design is provided
in which a motion is imparted to a lever using a gear and in which the lever cannot move the
gear. In an exemplary embodiment of the invention, the diode comprises a gear or lever

WO 2005/074373 PCT/IL2005/000142

engaging a worm gear with a low enough lead angle (i.e., not back driven) a motor turns the
worm gear, thereby moving the gear and/or a lever attached thereto. Due to the low lead angle,
when the gear rotates, the worm gear moves axially rather than rotates. Optionally, the worm
gear sits on springs or another elastic element which provide a degree of resiliency to motion
5 of the gear. Optionally, the springs are pre-stressed to a desired amount. Optionally, the worm
gear is rotated to follow motion of the lever and maintain a desired tension and/or symmetry in
the elastic element(s).

An aspect of some embodiments of the invention relates to a manual manipulator
which moves or controls movement of a human body using at least one wire and optionally

10 one or more robotic elements, so that motion in 3D of at least one point of the body is
constrained by the manipulator. In an exemplary embodiment of the invention, the manipulator
is configured for use as a rehabilitation device. Optionally, one or more motors are provided to
move the at least one point. Optionally, one or more resilient elements are provided to allow
some slack with resiliency to be provided in one or more wires. Optionally, three wires are

1 5 provided to constrain 3D motion.

An aspect of some embodiments of the invention relates to patient positioning in a
rehabilitation system. In an exemplary embodiment of the invention, the system determines
patient position using an imaging system. In an exemplary embodiment of the invention,
alternatively or additionally, a location of a chair or other support for the patient, relative to the

20 system, is determined. Optionally, a spring-loaded wire system is used to measure the relative
positions. Optionally, a pressure sensitive mat is used.

In an exemplary embodiment of the invention, the patient is instructed to perform one
or more motions and the relative positions are determined from the trajectories of the motions.
Optionally, position is determined in 2D, rather than in 3D. Alternatively, 3D position and/or

25 orientation information is determined.

In an exemplary embodiment of the invention, a moving part of the system itself or a
light pointer portion of the system are used to mark and/or note a correct positioning.

In an exemplary embodiment of the invention, once the relative position is determined,
one or more exercises are modified to take into account the relative positions.

30 An aspect of some embodiments of the invention relates to safety of a rehabilitation

device. In an exemplary embodiment of the invention, the rehabilitation device includes one or
more mechanical fuses which selectively tear when shear, strain and/or torque on a replaceable
element (such as a pin) increase above a threshold. Alternatively to a mechanical pin, an

WO 2005/074373 PCT/IL2005/000142

adjustable magnetic pin may be used, in which two parts of a pin attach to each other based on
magnetic attraction. The attraction level is optionally set by moving a magnet inside one of the
parts of the pin. Torque is optionally detected by providing a serrated connection between the
pin parts which links relative rotation of the pin parts and separation of the parts. Optionally, a
5 wire is provided in the pin so that tearing of the wire can be detected by the device electrically.

In an exemplary embodiment of the invention, a dead-man switch is provided for a
patient in which if a patient lets go of the switch, the device stops or goes into a predefined or
dynamically determined safe mode and/or position. Optionally, the dead-man switch is on a
wireless element held by a good limb or body part, for example, being stepped on, held by

1 0 hand or held in a mouth.

In an exemplary embodiment of the invention, a voice activated shut-off is provided,
for example to allow a patient to stop the rehabilitation by shouting.

In an exemplary embodiment of the invention, the rehabilitation device analyses
motions and/or forces applied by the patient, to detect problems. For example, any gross

1 5 irregularities will cause the rehabilitation device to stop.

In an exemplary embodiment of the invention, the device includes at least one moving
element which includes resiliency when moving so that there is slack, with increasing
resistance as amount of slack used increases. Optionally, the slack serves to allow a user to not
perform a motion according to the movement of the element, while providing sufficient time to

20 detect that the motion is incorrect and that applied forces are reaching a safety limit.

Examples of types of situations where embodiments of the invention may be useful,
follow. In some exemplary embodiments of the invention, a range of treatment lengths are
supported, including for example, goal oriented treatment, short term treatment, long term
treatment and/or preventive activities. In some exemplary embodiments of the invention,

25 treatment over multiple stages in rehabilitation, possibly an entire rehabilitation process, are
supported, in some cases with a same device. In some exemplary embodiments of the
invention, multiple body parts may be rehabilitated, either simultaneously or separately, in
some cases, with a same device. In some embodiments of the invention, multiple modalities
are rehabilitated, either together or using a same device, for example, motor control, motor

30 feedback, vision, audio ability and/or speech. A range of complexities and hierarchies of
motion are supported by some embodiments, for example, simple motion of one joint and
complex planning of multi-limb motion. Multiple treatment locations are supported by some
embodiments of the invention, for example, ICU, bed, clinic, home and/or outdoor. Multiple

WO 2005/074373 PCT/IL2005/000142

activity types are supported in some embodiments of the invention, for example, dedicated
rehabilitation exercises, training exercises, daily activities, outdoor activities and/or diagnosis
activities. In some embodiments of the invention, multiple body positions are supported, for
example, lying down, standing and/or sitting. In some embodiments of the invention, a range
5 of mental, cognitive and/or motor ability states are supported. It should be noted that not all the
embodiments of the invention support all the various ranges and the extents of the ranges
described above.

There is thus provided in accordance with an exemplary embodiment of the invention a
method of rehabilitation using an actuator type that includes a movement mechanism capable
10 of applying a force that interacts with a motion of a patient's limb in a volume of at least 30 cm
in diameter, in at least three degrees of freedom of motion of the actuator and capable of
preventing substantial motion in any point in any direction in said volume, comprising:

exercising a patient at a first place of rehabilitation selected from a bed, a wheel-chair,
a clinic and a home, using an actuator of said actuator type which interacts with a motion of
1 5 said patient; and

second exercising said patient at a second place of rehabilitation selected from a bed, a
wheel-chair, a clinic and a home using a second actuator of said actuator type which interacts
with a motion of said patient;

wherein said first exercising and said second exercising utilize a same movement
20 mechanism design for moving the actuators.

Optionally, said first and said second exercising are performed using a same
rehabilitation apparatus.

In an exemplary embodiment of the invention, said motion mechanism is motorized.
Optionally, said motion and said force are controlled by a controller. Alternatively or
25 additionally, said motion mechanism is capable of applying a force of at least 10 Kg to a tip of
said actuator. Alternatively or additionally, said motion mechanism is capable of applying a
force of different magnitudes in different directions of motion said actuator.

In an exemplary embodiment of the invention, said motion mechanism is adapted to
apply selective resistance to motion of said actuator.
30 In an exemplary embodiment of the invention, said actuator is adapted to interact with

said motion in a plurality of modes including at least causing said motion, guiding said motion
and recoding said motion. Optionally, said first and said second exercising use different
motion interaction modes.

WO 2005/074373 PCT/IL2005/000142

In an exemplary embodiment of the invention, at least one of said first and said second
exercising are performed in water.

In an exemplary embodiment of the invention, said first and said second exercising are
performed on a same limb.
5 In an exemplary embodiment of the invention, said first and said second exercising are

different exercises.

In an exemplary embodiment of the invention, the method comprises keeping track of
progress of said patient including said first and said second exercising, in a same controller
coupled with said second actuator.
10 Optionally, said actuator is rigid.

There is also provided in accordance with an exemplary embodiment of the invention a
method of rehabilitation using an actuator that includes a movement mechanism capable of
applying a force that interacts with a motion of a patient's limb in a volume of at least 30 cm in
diameter, in at least three degrees of freedom of motion of the actuator and capable of
15 preventing substantial motion in any point in any direction in said volume, comprising:

exercising a first organ type of a patient using said actuator; and

exercising a second organ type of the patient using said actuator.

In an exemplary embodiment of the invention, the method comprises replacing an
attachment to said patient of said rehabilitation device between said exercising.
20 In an exemplary embodiment of the invention, the actuator comprises a controller

which controls said interaction. Optionally, said controller is programmed with a plurality of
different exercises for different limbs

In an exemplary embodiment of the invention, the method comprises adjusting at least
one of a spatial position and orientation of said actuator relative to said patient, between said
25 exercises.

There is also provided in accordance with an exemplary embodiment of the invention a
rehabilitation kit, comprising:

an actuator that includes a movement mechanism capable of applying a force that
interacts with a motion of a patient's limb in a volume of at least 30 cm in diameter, in at least
30 three degrees of freedom of motion of the actuator and capable of preventing substantial
motion in any point in any direction in said volume;

a tip on said actuator; and

a plurality of attachments modularly exchangeable for said tip, at least two of which are

WO 2005/074373 PCT/IL2005/000142

adapted to fit different organs.

Optionally, at least one of said attachments is powered via said actuator. Alternatively
or additionally, at least one of said attachments is capable of rotation in three axes of rotations.

There is also provided in accordance with an exemplary embodiment of the invention a
5 device for rehabilitation, comprising:

a motorized actuator adapted to support a movement by a person by at least one of
resisting motion, guiding motion and causing motion; and

a controller configured to control said actuator,

wherein, said controller is programmed to provide rehabilitation exercising for patients
1 0 switchable between a plurality of modes in which one or more or motivation, cognitive ability
and motor ability is either high or low.

Optionally, said controller is configured to provide instructions in a selectable one of at
least three information presentation modes and complexity levels.

Alternatively or additionally, said controller is configured to provide support for motor
15 activity of said patient in a selectable one of at least three levels of assistance.

Alternatively or additionally, said controller is configured to provide incentive
feedback to said patient in a selectable one of at least three levels of incentive.

There is also provided in accordance with an exemplary embodiment of the invention a
method of rehabilitation using an actuator that includes a movement mechanism capable of
20 applying a force that interacts with a motion of a patient's limb in a volume of at least 30 cm in
diameter, in at least three degrees of freedom of motion of the actuator and capable of
preventing substantial motion in any point in any direction in said volume, comprising:

coupling said actuator to a person in a home setting;

performing a daily activity by said person, wherein said actuator interacts with said
25 activity to enhance rehabilitation.

Optionally, said daily activity is outdoors

Alternatively or additionally, said actuator interacts using a stored rehabilitation plan.
Alternatively or additionally, said actuator reports to a remote location on a progress of
rehabilitation.

30 Alternatively or additionally, said actuator prevents unsafe motions by said patient.

Alternatively or additionally, the method comprises first practicing said daily activity at
a rehabilitation clinic.

There is also provided in accordance with an exemplary embodiment of the invention a

WO 2005/074373 PCT/IL2005/000142

method of rehabilitation, comprising:

rehabilitating a first patient on a first rehabilitation device;

rehabilitating a second patient on a second rehabilitation device; and

passing information regarding rehabilitation between said two devices, said
5 information including at least one of a score, current progress, spatial position of a portion of
the patient and a game play.

Optionally, said patients play a game together using said devices for input and output.
Optionally, said patients play against each other. Alternatively or additionally, said first
rehabilitation device provides a different support fro said first patient than said second device
10 supplies for said second patient, to compensate for differences in ability between the two
patients.

In an exemplary embodiment of the invention, said information is passed in real-time.
In an exemplary embodiment of the invention, said information is passed using a
wireless connection.

15 In an exemplary embodiment of the invention, the method comprises monitoring said

first and said second patients by a remote therapist.

In an exemplary embodiment of the invention, the method comprises remotely
connecting into a therapy group by said patients.

In an exemplary embodiment of the invention, said two devices are in a same room.
20 There is also provided in accordance with an exemplary embodiment of the invention a

rehabilitation system configuration, comprising:
A first rehabilitation device; and

A second rehabilitation device linked by a wireless data link with said first
rehabilitation device such that the two rehabilitation devices can act in synchrony.
25 There is also provided in accordance with an exemplary embodiment of the invention a

method of cooperative rehabilitation, comprising:

providing a first actuator that includes a movement mechanism capable of applying a
force that interacts with a motion of a patient's limb in a volume of at least 30 cm in diameter,
in at least three degrees of freedom of motion of the actuator and capable of preventing
30 substantial motion in any point in any direction in said volume;

providing a second actuator that includes a movement mechanism capable of applying
a force that interacts with a motion of a patient's limb in a volume of at least 30 cm in
diameter, in at least three degrees of freedom of motion of the actuator and capable of

WO 2005/074373 PCT/IL2005/000142

preventing substantial motion in any point in any direction in said volume;

engaging said first and said second actuators by a patient and by a non-therapist,
respectively; and

rehabilitating said patient using said first actuator and said non-therapist.
Optionally, said non-therapist is a blood relative.

In an exemplary embodiment of the invention, the method comprises guiding said non-
therapist and said patient by instructions by a controller.

In an exemplary embodiment of the invention, said non-therapist is under an age of 18.

In an exemplary embodiment of the invention, said non-therapist is under an age of 10.

In an exemplary embodiment of the invention, said providing is at a home of said non-
therapist.

In an exemplary embodiment of the invention, said non-therapist has fewer than 50
hours experience in physical therapy.

In an exemplary embodiment of the invention, said non-therapist has fewer than 10
hours experience in physical therapy.

There is also provided in accordance with an exemplary embodiment of the invention a
rehabilitation device comprising:

a frame;

an actuator that includes a movement mechanism capable of applying a force that
interacts with a motion of a patient's limb in a volume of at least 30 cm in diameter, in at least
three degrees of freedom of motion of the actuator and capable of preventing substantial
motion in any point in any direction in said volume;

a joint interconnecting said frame and said actuator and allowing multiple different
relative placements of said movement mechanism on said frame, such that said volume moves
relative to said frame.

Optionally, said motion mechanism has different motion limitations in different spatial
direction and wherein said multiple relative placements include changing an orientation of said
mechanism.

In an exemplary embodiment of the invention, said joint comprises a linear joint.

In an exemplary embodiment of the invention, said joint comprises a swiveling joint.

In an exemplary embodiment of the invention, said frame is curved.

In an exemplary embodiment of the invention, said joint is motorized.

In an exemplary embodiment of the invention, the device comprises a controller that

WO 2005/074373 PCT/IL2005/000142

controls said joint according to an exercise stored in said controller to be performed.

In an exemplary embodiment of the invention, the device comprises at least one sensor
that reports a position of said joint.

There is also provided in accordance with an exemplary embodiment of the invention a
5 method of setting up a rehabilitation system including an actuator that includes a movement
mechanism capable of applying a force that interacts with a motion of a patient's limb in a
volume of at least 30 cm in diameter, in at least three degrees of freedom of motion of the
actuator and capable of preventing substantial motion in any point in any direction in said
volume, comprising:
10 determining a rehabilitation exercise to be performed;

selecting a desired position for said motion control mechanism for said exercise; and

adjusting a position of the mechanism on a frame according to said desired position.

In an exemplary embodiment of the invention, the method comprises automatically
adjusting said position.

15 In an exemplary embodiment of the invention, the method comprises automatically

reporting to a user said desired position.

There is also provided in accordance with an exemplary embodiment of the invention a
rehabilitation device, comprising:

a joint having freedom of motion in Phi (rotation) and Theta (elevation) spherical
20 angles, said freedom allowing positioning of said joint in substantially any angular position
within a range of at least 30 degrees in each angular direction.

a substantially rigid radial extension attached to said joint and adapted for movement
with a limb of a person at at least one point thereof; and

a controller adapted to control motion of said joint and thereby motion of said radial
25 extension.

In an exemplary embodiment of the invention, said radial extension is balanced such
that said point remains stable if no force is applied and moves if force is applied by said
person. Optionally, said balancing can be varied to match a weight of an attachment selectively
attached to said extension. Alternatively or additionally, said balancing can be varied by said
30 controller along a path of motion to match a change in moment on said point. Alternatively or
additionally, said balancing can be set to provide a neutral buoyancy to said limb.

In an exemplary embodiment of the invention, said joint is a ball joint.

In an exemplary embodiment of the invention, said joint comprises two orthogonal

WO 2005/074373 PCT/IL2005/000142

hinges with a common center of rotation.

In an exemplary embodiment of the invention, said controller comprises a mechanical
controller.

In an exemplary embodiment of the invention, said controller comprises an electrical
5 controller.

In an exemplary embodiment of the invention, the device comprises at least one brake
adapted to selectively resist said freedom motion. Optionally, said brake is continuously
controlled by said controller. Alternatively or additionally, said brake is uni-directional in only
one of said Phi and Theta directions. Alternatively or additionally, said brake is operative in

10 both said Phi and said Theta directions.

In an exemplary embodiment of the invention, the device comprises at least one motor
adapted to move said joint. Optionally, said motor is adapted to apply at least 10 Kg of force at
said point. Alternatively or additionally, said motor is continuously controlled by said
controller. Alternatively or additionally, said motor cannot be back-driven by said extension.

15 In an exemplary embodiment of the invention, the device comprises at least one

resilient element adapted to provide resilient compliance when said person moves said point in
a trajectory other than a trajectory for which motion is controlled to move by said controller.
Optionally, said controller sets a degree of said resilient compliance.

In an exemplary embodiment of the invention, said element is extendible.

20 In an exemplary embodiment of the invention, element includes a conduit for electrical

power.

In an exemplary embodiment of the invention, the device comprises at least one
position sensor which reports on a angular position of said joint.

In an exemplary embodiment of the invention, the device comprises at least one force
25 sensor which reports on a force applied to said joint.

In an exemplary embodiment of the invention, said controller is configured to control
said motion and provide at least one of assisting motion by said patient limb, resisting motion
by said patient limb, guiding motion by said patient limb, nudging said patient limb to move
and moving said patient limb.
30 In an exemplary embodiment of the invention, said controllers stores thereon a plurality

of different rehabilitation exercises.

There is also provided in accordance with an exemplary embodiment of the invention a
balanced rehabilitation device, comprising

WO 2005/074373 PCT/IL2005/000142

at least one weight that balances said actuator such that no force is required to maintain
said actuator in space.

There is also provided in accordance with an exemplary embodiment of the invention a
method of rehabilitation, comprising:

assisting motion in space of a patient along a trajectory, using an actuator;

providing resistance to motion by said patient away from said trajectory, said resistance
including compliance in a direction away from said trajectory,

wherein said compliance is achieved mechanically without an electro-mechanical
feedback loop.

In an exemplary embodiment of the invention, said compliance is provided by braking.
In an exemplary embodiment of the invention, said compliance is provided by at least
one resilient element.

In an exemplary embodiment of the invention, the method comprises tracking said
motion of the patient with said compliance.

In an exemplary embodiment of the invention, a different force of resistance is
provided at different points in space along the motion.

In an exemplary embodiment of the invention, a different force of resistance is
provided at different direction at a same point in space.

In an exemplary embodiment of the invention, said compliance is at least 1 cm.

There is also provided in accordance with an exemplary embodiment of the invention a
rehabilitation device comprising:

a lever adapted to move together with a portion of a patient's body;

a motor, operatively connected to said lever in a manner which prevents back-driving
of the motor by said lever, said motor being operative to move the lever; and

a spring coupled to said lever and providing resilience to said motion.

In an exemplary embodiment of the invention, said spring provides said resilience only
when said lever is moved different from motion caused by the motor.

In an exemplary embodiment of the invention, attempted back-driving of said motor
applies force to said spring.

WO 2005/074373 PCT/IL2005/000142

In an exemplary embodiment of the invention, said spring has a controllable pre-load.
In an exemplary embodiment of the invention, the device comprises a damping element
in parallel with said spring.

There is also provided in accordance with an exemplary embodiment of the invention a
5 rehabilitation device comprising:

a lever adapted to move together with a portion of a patient's body;
a motor, operatively connected to said lever to move the lever;
a slot guiding motion of said lever; and

a spring coupled to said lever and providing resilience to said motion.
10 In an exemplary embodiment of the invention, said spring is mounted on said slot.

There is also provided in accordance with an exemplary embodiment of the invention a
multi-axis resilient element for rehabilitation, comprising:

a first set of at least one joint adapted to allow motion in spherical coordinates of a
radially extending lever;

15 a second set of at least one joint adapted to allow motion in spherical coordinates of

said first set;

a resilient element having a compression associated with motion of said lever thereby
compliance to motion in said second set.

In an exemplary embodiment of the invention, said resilient element has a settable pre-

20 load.

There is also provided in accordance with an exemplary embodiment of the invention a
rehabilitation device comprising:

a lever adapted to move together with a portion of a patient's body;
a motor, operatively connected to said lever to move the lever; and
25 a spring coupled to said lever and providing resilience to said motion,

wherein said spring has a settable compliance.

In an exemplary embodiment of the invention, said compliance is set by a controller.
Optionally, said setting is continuous.

In an exemplary embodiment of the invention, said spring is a flat spring having a
30 settable effective length.

There is also provided in accordance with an exemplary embodiment of the invention a
telescoping mechanism comprising:

at least three telescoping sections, including a central section and two end sections;

WO 2005/074373 PCT/IL2005/000142

an actuating mechanism that extends said central section;

a first rack and pinion mechanism that couples motion of one of said ends and of said
central portion;

a second rack and pinion mechanism that couples motion of the other one of said ends
and of said central portion; and

a belt operatively linking the two rack and pinion mechanisms.

There is also provided in accordance with an exemplary embodiment of the invention a
portable rehabilitation device comprising:

a base for stabilization of the device to a surface or object; and

wherein said device has two configurations:

a first configuration suitable for practicing rehabilitation; and
a second configuration suitable for storage, and wherein

said device is adapted to pass between said configurations manually, by a layman.

In an exemplary embodiment of the invention, said device is taken apart for said
second configuration.

In an exemplary embodiment of the invention, said device comprises at least one
quick-connection.

In an exemplary embodiment of the invention, said device folds down.

In an exemplary embodiment of the invention, said device folds flat to fit in a car trunk.

In an exemplary embodiment of the invention, said device weighs less than 30 Kg.

In an exemplary embodiment of the invention, said device is wheeled

There is also provided in accordance with an exemplary embodiment of the invention a
rehabilitation device, comprising:

a lever adapted to move together with a portion of a patient's body;

at least one motor coupled to said lever adapted to interact with a motion of said lever;

and

at least one separable element interconnecting said motor and said lever and adapted to
decouple at least a portion of said lever from said motor is a predetermined force on the
element is exceeded.

WO 2005/074373 PCT/IL2005/000142

In an exemplary embodiment of the invention, said element comprises a tearing pin.
In an exemplary embodiment of the invention, said element comprises a separable

joint.

In an exemplary embodiment of the invention, said element is connected between a
body of said lever and an attachment mounted on said lever.

There is also provided in accordance with an exemplary embodiment of the invention a
rehabilitation device, comprising:

a lever adapted to move together with a portion of a patient's body;

at least one motor coupled to said lever adapted to interact with a motion of said lever;

at least one resilient element interconnecting said motor and said portion; and

a controller adapted to identify a safety problem and stop said motor upon said
identifying, said resilient element preventing such stopping from being immediate.

In an exemplary embodiment of the invention, said device comprises an actuator that
includes a movement mechanism capable of applying a force to said lever which lever interacts
with a motion of a patient's limb in a volume of at least 30 cm in diameter, in at least three
degrees of freedom of motion of the lever.

In an exemplary embodiment of the invention, said controller identifies said safety
problem by detecting a shout by said patient.

In an exemplary embodiment of the invention, said controller identifies said safety
problem by calculating at least one position of a point of the body of said patient and
comparing the result of the calculation to one or more allowed value.

There is also provided in accordance with an exemplary embodiment of the invention a
rehabilitation docking station comprising:

at least one actuator adapted to assist in rehabilitation by; and

a docking port adapted for locking to a patient carrier.

In an exemplary embodiment of the invention, said port is adapted to engage a
wheelchair.

In an exemplary embodiment of the invention, said port is adapted to engage a bed.
In an exemplary embodiment of the invention, said station is mobile.

WO 2005/074373 PCT/IL2005/000142

In an exemplary embodiment of the invention, said station includes at least one port for
attachment of a second actuator thereto.

There is also provided in accordance with an exemplary embodiment of the invention a
method of rehabilitation comprising:

providing an actuator that includes a movement mechanism capable of applying a force
that interacts with a motion of a patient's limb in a volume of at least 30 cm in diameter, in at
least three degrees of freedom of motion of the actuator and capable of preventing substantial
motion in any point in any direction in said volume;

coupling said actuator to a point on a human body;

applying a force vector to said point by said actuator, said force including a rotation.

In an exemplary embodiment of the invention, said force vector includes at least two
rotations directions relative to the force vector.

In an exemplary embodiment of the invention, the method comprises applying a second
force to at least a second point on said body, simultaneously with said force.

There is also provided in accordance with an exemplary embodiment of the invention a
method of rehabilitation comprising:

providing a first actuator that includes a movement mechanism capable of applying a
force that interacts with a motion of a patient's limb in a volume of at least 30 cm in diameter,
in at least three degrees of freedom of motion of the actuator and capable of preventing
substantial motion in any point in any direction in said volume;

coupling said first actuator to a first point on a human body;

coupling said second actuator to a second point on a human body; and

applying different forces to said points using said actuators.

In an exemplary embodiment of the invention, said first actuator applies a rotation.

In an exemplary embodiment of the invention, said different points are on a same limb.

In an exemplary embodiment of the invention, said different points are on different
limbs. In an exemplary embodiment of the invention, the method comprises exercising the two
limbs in concert. Alternatively or additionally, the method comprises copying motion from one
limb to the other limb.

WO 2005/074373 PCT/IL2005/000142

There is also provided in accordance with an exemplary embodiment of the invention a
method of reverse kinematics, comprising:

controlling motion of at least one point on an organ using an actuator that includes a
movement mechanism capable of applying a force that interacts with a motion of a patient's
5 limb in a volume of at least 30 cm in diameter, in at least three degrees of freedom of motion
of the actuator and capable of preventing substantial motion in any point in any direction in
said volume;

controlling a position of at least a second point on the organ; and

reconstructing by a computer of a value of a bending of at least one joint of said organ
10 from said motion and said position.

There is also provided in accordance with an exemplary embodiment of the invention a
rehabilitation device, comprising:

an actuator that includes a movement mechanism capable of applying a force that
interacts with a motion of a patient's limb in a volume of at least 30 cm in diameter;
15 a support for a patient; and

a controller adapted to adjust a rehabilitation exercise according to the relative
positions of said actuator and at least one of said patient and said support.

In an exemplary embodiment of the invention, the device comprises a distance sensor
for determining said relative positions.
20 In an exemplary embodiment of the invention, the device comprises an imaging sensor

for determining said relative positions.

In an exemplary embodiment of the invention, said controller relates to the relative
placement of said patient and said actuator.

In an exemplary embodiment of the invention, said controller assumes the relative
25 positions differ only in two dimensions.

In an exemplary embodiment of the invention, the device comprises a pointer which
indicates a desired patient placement.

In an exemplary embodiment of the invention, said controller is configured to use said
actuator to determine said relative placement.
30 In an exemplary embodiment of the invention, said controller is configured to use said

actuator to indicate a desired relative placement.

In an exemplary embodiment of the invention, said controller is configured to adjust
said exercise on the fly, during an exercise session and in response to patient movement.

WO 2005/074373 PCT/IL2005/000142

There is also provided in accordance with an exemplary embodiment of the invention a
rehabilitation device, comprising:

a memory storing therein a correspondence between exercises and payment codes;

a controller adapted to control a rehabilitating exercise and generate a report including
a code from said memory corresponding to said exercise.

There is also provided in accordance with an exemplary embodiment of the invention a
rehabilitation device, comprising:

at least one actuator adapted to support motion of a body part;

at lest one sensor associated with the actuator and measuring said motion; and

a controller which analyses said measured motion and generates a measure of quality of
motion and which modifies a rehabilitation plan responsive to said quality of motion measure.

In an exemplary embodiment of the invention, the controller modifies a selection of
future exercises according to a measured quality of motion.

In an exemplary embodiment of the invention, the controller modifies a selection of
parameters for future exercises according to a measured quality of motion.

In an exemplary embodiment of the invention, the quality of motion measure used is
defined as the degree of matching to a 2/3 power law.

There is also provided in accordance with an exemplary embodiment of the invention a
method of rehabilitation, comprising:

causing a person to carry out at least one exercise;

estimating a mental state of said person from a result of said at least one exercise; and

automatically selecting at least one second exercise according to said estimation.

In an exemplary embodiment of the invention, estimating a mental step comprises

comparing performance between two exercises, one or which is expected to elicit a higher

compliance.

In an exemplary embodiment of the invention, estimating a mental step comprises
comparing performance within an exercise, using the maximum ability of the patient as a base
line against which variation can be determined.

In an exemplary embodiment of the invention, said estimating is automatic.

There is also provided in accordance with an exemplary embodiment of the invention a
method of rehabilitation, comprising:

determining a patient's ability to perform a motor task;

determining a patient's ability to perform a non-motor task; and

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automatically selecting an exercise or parameters of an exercise for the patient
according to said determinations.

In an exemplary embodiment of the invention, said selecting comprises matching an
instruction or feedback modality to a perceptive ability.
5 In an exemplary embodiment of the invention, said selecting comprises matching an

instruction or feedback modality to a cognitive ability.

In an exemplary embodiment of the invention, said selecting comprises an exercise or
series of exercises designed to rehabilitate both of said motor and said non-motor abilities.

In an exemplary embodiment of the invention, said exercise rehabilitates visual-motor
1 0 coordination.

There is also provided in accordance with an exemplary embodiment of the invention a
method of rehabilitation comprising;

moving a motorized actuator having a tip to a spatial position within a volume having a
diameter of at least 30 cm; and
15 instructing a patient to apply force against said tip, wherein said actuator provides a

compliant resistance to said force. Optionally, the method comprises selecting the resistance
according to the spatial location.

BRIEF DESCRIPTION OF THE FIGURES
Non-limiting embodiments of the invention will be described with reference to the
20 following description of exemplary embodiments, in conjunction with the figures. The figures
are generally not shown to scale and any sizes are only meant to be exemplary and not
necessarily limiting. In the figures, identical structures, elements or parts that appear in more
than one figure are preferably labeled with a same or similar number in all the figures in which
they appear, in which:

25 Fig. 1 is a schematic showing of an articulated-arm based rehabilitation device, in

accordance with an exemplary embodiment of the invention;

Fig. 2 is a schematic block diagram of a remote rehabilitation system, in accordance
with an exemplary embodiment of the invention;

Fig. 3A illustrates a force field generated by a rehabilitation device in accordance with
30 an exemplary embodiment of the invention;

Fig. 3B shows an exemplary profile of a force of resistance;

Fig. 4 A is a flowchart of a method of using a rehabilitation device, in accordance with
an exemplary embodiment of the invention;

WO 2005/074373 PCT/IL2005/000142

Fig. 4B is a flowchart of a long term use of a rehabilitation device, in accordance with
an exemplary embodiment of the invention;

Fig. 5 illustrates a system including limb position sensing, in accordance with an
exemplary embodiment of the invention;
5 Fig. 6 illustrates an elbow holding attachment, in accordance with an exemplary

embodiment of the invention;

Figs. 7 and 8 illustrate two hand rehabilitation devices, in accordance with exemplary
embodiments of the invention;

Figs. 9 A and 9B illustrate devices for controlled motion of more than one point in a
10 body, in accordance with exemplary embodiments of the invention;

Fig. 10 shows a ball-based rehabilitation device, in accordance with an exemplary
embodiment of the invention;

Fig. 1 1 shows a balancing of the rehabilitation device of Fig. 10, in accordance with an
exemplary embodiment of the invention;
15 Fig. 12 illustrates a drive system for a plate-based rehabilitation device, in accordance

with an exemplary embodiment of the invention;

Fig.l3A illustrates a coupling device for a plate drive system, in accordance with an
exemplary embodiment of the invention;

Fig. 13B illustrates a plate with a flexible slot, in accordance with an exemplary
20 embodiment of the invention;

Fig. 14A illustrates a two plate rehabilitation device, in accordance with an exemplary
embodiment of the invention;

Figs 14B and 14C illustrate guide plates in accordance with exemplary embodiments of
the invention;

25 Fig. 15A shows a wrist attachment, which provides control and/or feedback for one or

more degrees of motion of a hand, in accordance with an exemplary embodiment of the
invention;

Figs. 15B-15F show various attachments according to exemplary embodiments of the
invention;

30 Figs. 16A-16D illustrate various methods of elbow support in accordance with

exemplary embodiments of the invention;

Fig. 17A illustrates a rehabilitation device with varying orientation, in accordance with
an exemplary embodiment of the invention;

WO 2005/074373 PCT/IL2005/000142

Figs. 17B and 17C show an alternative rehabilitation device with varying orientation,
in accordance with an exemplary embodiment of the invention;

Fig. 17D shows an alternative rehabilitation device with varying orientation, in
accordance with an exemplary embodiment of the invention;

Fig. 18 shows a rehabilitation device for an arm and a leg, in accordance with an
exemplary embodiment of the invention;

Fig. 19A shows a rehabilitation device for two sides of a body, in accordance with an
exemplary embodiment of the invention;

Fig. 19B shows a docking station, in accordance with an exemplary embodiment of the
invention;

Fig. 19C shows an occupied docking station of the type shown in Fig. 19B;

Fig. 19D shows mobile rehabilitation devices positioned near a bed, in accordance with
an exemplary embodiment of the invention;

Fig. 19E shows an alternative mobile rehabilitation device, coupled to a bed, in
accordance with an exemplary embodiment of the invention;

Fig. 19F exemplifies the use of mobile rehabilitation devices in a bathtub, in
accordance with an exemplary embodiment of the invention;

Fig. 19G shows a rehabilitation device configured for use for daily activities, in
accordance with an exemplary embodiment of the invention;

Fig. 19H shows a device for assisting in training for activities of daily living, in
accordance with an exemplary embodiment of the invention;

Fig. 20 shows a chuck mechanism in accordance with an exemplary embodiment of the
invention;

Fig. 21 shows an alternative non-ball, balanced, rehabilitation device, in accordance
with an exemplary embodiment of the invention;

Fig. 22A shows another alternative non-ball rehabilitation device mechanism, in
accordance with an exemplary embodiment of the invention;

Fig. 22B shows force control mechanisms and brakes attached to the device of Fig.

22A;

Fig. 23 shows a cantilevered rehabilitation device mechanism, in accordance with an
exemplary embodiment of the invention;

Fig. 24A is a side cross-sectional view of a force control mechanism as used in Fig.
22B, in accordance with an exemplary embodiment of the invention;

WO 2005/074373 PCT/IL2005/000142

Fig. 24B is a flowchart of the operation of the mechanism of Fig. 24A, in accordance
with an exemplary embodiment of the invention;

Fig. 25 shows a force control mechanism in accordance with an alternative
embodiment of the invention;
5 Fig. 26A shows a Z-axis extension mechanism in accordance with an exemplary

embodiment of the invention; and

Fig. 26B shows a force control mechanism for an attachment, exemplified as part of
Fig. 26 A, in accordance with an exemplary embodiment of the invention.

DETAILED DESCRIPTION OF EXEMPLARY EMBODIMENTS

10 General

The methods and apparatus of some embodiments of the invention provide for
controlled, partially controlled or directed motion of portions of the body. The following
sections describe this equipment by first describing the design of an exemplary device (an
articulated arm), followed by various rehabilitation methods and then additional rehabilitation

15 device designs and uses. The invention should not be considered as being limited to particular
devices used to illustrate particular methods. Rather, many of the methods can be practiced
with a variety of devices and many of the devices can be used to practice a variety of methods.
Articulated arm design

Fig. 1 is a schematic showing of an articulated-arm based rehabilitation device 100, in

20 accordance with an exemplary embodiment of the invention. In some of the description device
100 is referred to even though other devices described herein would suit just as well. The term
"system" is used in some places instead of referring directly to device 100 and may also
include multiple devices and monitors.

Device 100 comprises an articulated arm 102 that projects upwards out of a table or

25 other pedestal 104. A tip 108 of arm 102 serves as a controlled point which can travel various
3D trajectories. Optionally, pedestal 104 is not attached to a floor but is instead weighted by an
optionally weighted base 1 06 (which may be located elsewhere than shown), to prevent tipping
or capsizing of device 100 during use. Optionally, base 106 includes electronics used to power
the arm. Alternatively or additionally, weight 106 is a temporary weight, for example a water-

30 filled bladder. Other exemplary general layouts are shown below.

In an exemplary embodiment of the invention, arm 102 is an articulated arm, which
supports movement in 3D space. Alternative designs, for example based on a single joint and
an extending arm, are described below.

WO 2005/074373 PCT/IL2005/000142

In an exemplary embodiment of the invention, arm 102 comprises a plurality of
sections 110 interconnected by a plurality of joints 112. In an exemplary embodiment of the
invention, each joint is motorized, for example as known in the art of robotic arms.
Alternatively or additionally, each joint is selectively lockable, for example as described
5 below. Optionally, angular position sensors are provided at each joint and/or a position sensor
at tip 108, so the position in space of arm 102 and/or of tip 108 can be determined. The joints
may be joints with one, two, three or more degrees of freedom.

In an exemplary embodiment of the invention, arm 102 (e.g., its locking and/or force
application and/or movement) is controlled by a controller 114, for example a personal
10 computer or a dedicated embedded computer. Optionally, a display 116 and/or a user input
device 118 are used for interaction with a user. Optionally, display 116 comprises (or is limited
to) an audio display, for example for providing audible and/or speech instruction and/or
feedback.

An external connection 120 for connection to a remote computer and/or other units, is

15 optionally provided, for example for use as described in Fig. 2 below.

It should be noted that some implementations of device 100 include no computer.
Some implementations require no electrical power. In one example, a mechanical computer is
used to control the device parameters. In some embodiments of the invention, resistance to
motion (optionally variable) is provided using a brake system.

20 Arm Specification

As will be described below in greater detail, various rehabilitation methods in
accordance with exemplary embodiments of the invention require different types of motion
and/or responsiveness from arm 102 or other devices as described below. In some
embodiments of the invention the use of device 1 00 for rehabilitation places certain constraints

25 on device 100, with respect to, for example, smoothness of motion, responsiveness, coupling
between axes, balancing and/or supported range of motion.

For example, some types of rehabilitation in accordance with exemplary embodiments
of the invention require a patient to move tip 108 along a trajectory. Resistance may be
predefined along the trajectory or possibly no resistance at all is provided. In any case, it may

30 be desirable that device 100 not adversely affect motions by the patient, at least if they are
correct. In a particular example, tip 108 provides no resistance to motion along a certain
trajectory and strongly resists motion not along the certain trajectory. Such a tip is termed a
neutral directed motion tip.

WO 2005/074373 PCT/IL2005/000142

In order to support generalized 3D trajectories in a neutral manner (e.g., not providing
resistance at least along the trajectory of motion), arm 102 is optionally required to not have
singularity points in a predefined and useful range of motion, for example a sphere of radius of
0.8 meters or less, for example, 0.5 meters or less. The term "singularity" is used to define a
5 point and arm position where moving to an adjacent point passes the limits of one or more
joints and requires a relatively large change in joints position, which is generally time
consuming and is exhibited to a patient as a sudden resistance or delay. In addition, providing
neutral motion means that a uniform (and desirably zero) resistance can be provided at any
point in a desired range of motion. Possibly more important in some embodiments of the

10 invention is that any changes in resistance be smoothly varying. In some embodiments, arm
102 provides a counter-force or even provides motion. Uniformity and controllability of such
force is required in some embodiments of the invention. In some embodiments, tip 108 is
configured to support a limb of a patient, so that the limb feels buoyant.

The magnitude of force that arm 102 can apply and/or resist depend on the

15 rehabilitation methods with which it is to be used. For example, one rehabilitation type will
require arm 102 to resist absolutely an incorrect motion, up to a force of, for example, 100 Kg
applied at tip 108. In another example, it is sufficient that arm 102 resists motion up to a force
level at which it is certain that the patient feels the resistance, for example, 1 Kg. A reminding
force may be useful in some embodiments, for example, 10 Kg, which may ensure that a

20 patient does not inadvertently move tip 108 against the force.

In an exemplary embodiment of the invention, the range of motion of tip 108 covers a
volume of 50x50x50 cm. In other embodiments, a smaller or larger volume is provided. The
volume need not be rectangular. Optionally, the volume also includes rotation of tip 108
around one, two or three axes. In some embodiments, the volume of movement of the tip is

25 one or two dimensional (i.e., in a plane or along a line).

In some embodiments of the invention arm 102 is expected to respond to a patient's
activity in a manner which will seem natural or at least not interfere with the rehabilitation
motion. In an exemplary embodiment of the invention, the responsiveness of arm 102 is faster
than 10 ms or better than 5 ms.

30 A general property of many mechanical systems is that due to manufacturing

tolerances, sensing tolerances, design and/or non-optimality of the construction some
uncontrollable freedom of motion is available. In an exemplary embodiment of the invention,
the amount of uncontrolled motion in device 100 is less than 5 mm or less than 2 mm. In some

WO 2005/074373 PCT/IL2005/000142

embodiments of the invention, a spring-loaded mechanism is used to prevent unrestrained
backlash motion.

Robotic technology for achieving such ranges of motion and responsiveness and forces
are well known, albeit possibly at a high cost. Various additional suitable technologies are
5 described below. Optionally, controller 114 controls arm 102 in a passive, active or a
responsive manner to achieve these objectives. In an exemplary embodiment of the invention,
such active control of arm 1 02 results in compensation for at least 80% or more of the moment
of inertia of arm 102. It should be noted that different values may be required for different
situations, for example a greater or lesser responsiveness or a greater or lesser uncontrollable
10 freedom.

Arm 102 is, for example, 1 meter, 0.8 meters, 0.5 meters, 0.3 meters or any greater
smaller or intermediate length.
Motion types

In device 100 as illustrated, the motion which is controlled is that of a single point, i.e.,
15 tip 108. By providing various attachments for tip 108, tip 108 may be connected, for example
to a bone, to a joint or to a different part of the body. The attachment may be rigid, for example
using a strap or it may depend on cooperation of or action by the patient, for example, as a
handle or a rest. Specific attachment devices, for example for a hand, arm, elbow, knee, ankle
and/or shoulder may be provided. Further, as described below, multiple tips 108 (optionally
20 with individual arms 102) may be provided for attachment at different points of the body, on a
same or different body part.

When providing rehabilitation various types of motion may be supported, for example,
one or more of:

a) Passive motion. Tip 108 is moved (by device 100) and the patient moves with it.
25 b) Resisted motion. The patient moves tip 108 and encounters resistance. The

resistance may be of various magnitudes and may be uniform in all direction or be directional.

c) Assisted motion. When a patient moves tip 108, a positive feedback on arm 102
increases the force of motion in the direction moved by the patient.

d) Force field motion. The patient moves tip 108. Along a certain trajectory one level
30 of resistance (or none) is encountered. Deviation from the trajectory is not allowed or meets

with resistance. Fig. 3A shows an example of such a force field. Motion along a "correct"
trajectory 302 can be without resistance, or possibly assisted. An increased resistance is
exhibited in a volume 304 surrounding trajectory 302. An even greater resistance is exhibited

WO 2005/074373 PCT/IL2005/000142

in a surrounding volume 306. A prevention of motion may be provided in an outside volume
308. In an exemplary embodiment of the invention, a corrective force vector 310 is applied
when not on trajectory 302, pointing towards trajectory 302. Optionally, instead of a corrective
force, resistance varies as a function of distance from trajectory 302, thus, motion of tip 108 is
5 naturally urged back to trajectory 302. Fig. 3B is a graph showing an exemplary relationship
between divergence from a path and applied force. Optionally, the force is applied in the
direction of the path. Alternatively, the force maybe a unidirectional force of resistance.
This type of motion may be used to help train the patient in a desired motion.

e) Mirrored motion. Motion of tip 108 is required to mirror the trajectory of motion of
1 0 a different element, for example for dual limb rehabilitation as described below.

f) Free motion. Patient moves tip 108 in any way he desires, possibly receiving
feedback. As the patient (or therapist or helper) moves tip 108, device 100, may record it for
future playback. In a playback mode the prerecorded motion (or path) is optionally
reconstructed using other modes. Optionally, the recorded path is modified (e.g., smoothed or

1 5 otherwise edited), for example automatically or manually.

g) General Force Field. A force field and/or an assistance field is defined which is not
related to any particular trajectory. For example, a range of trajectories may be allowed to be
practiced by a user, or a real or virtual situation simulated (e.g., water, areas with obstacles).

h) Local force field. A force field which is applied to only a small locality and/or only
20 in one or two dimensions.

i) Restricted motion. One or more points of the body of a subject are supported or
prevented from moving. Optionally, the angles between such points and the moving points on
the patient are measured. In one example the elbow is locked with a dedicated harness
allowing only a shoulder motion. In some embodiments, the restriction is partial and/or is

25 provided by a movable element (e.g., an arm 102).

j) Initiated Motion. The patient initiates the motion (e.g., a 1 cm motion or 100 gram
force) and device 100 completes or helps the patient complete the motion in space. The
completion may be of a whole trajectory or of part of a trajectory.

k) Implied motion. Device 100 begins the motion and the patient completes it. Device
30 100 may assist the rest of the motion in various manners (e.g., by changing to one of the modes
described herein after the motion starts). If the patient fails to pick up the motion, device 100
may generate a cue, for example an audio reminder. Different parts of a single motion
trajectory may each have a machine initiation definition. Optionally, if a patient is too slow in

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moving, device 100 begins the motion.

1) Cued motion. The patient receives a cue from the system before motion according to
a different mode starts. The cue can be, for example, vibration of tip 108, stimulation pads on
the skin, audio or visual cue. In some embodiments of the invention, the strength of the cue
5 and/or its timing and/or other ongoing activities (e.g., a visual display and game) are used to
help train the coordination between different modalities, for example, hand-eye coordination.
A motion cue can be used to train a kinesthetic sense.

m) Teach Mode. Device 100 is taught a motion. In one example, a therapist performs a
motion and motion parameters at each point are recorded and can then be used for an exercise.
10 Another way of teaching the system is to use a path that the therapist uses. The therapist may
use a control to indicate a point to be taught or a continuous mode may be defined by which an
entire trajectory is learned. Optionally the path and points are edited before replay. Optionally,
the paths are abstracted, for example, by smoothing or identifying motion points, before
playback.

1 5 Thus, in some embodiments of the invention, rehabilitation device 1 00 can provide one

or more of Isokinetic, Isotonic and Isostatic exercises.

It should be appreciated that a definition of a trajectory which tip 108 is to follow can

include speed parameters (e.g., trajectory of path, trajectory of velocity, trajectory of force).

For example, a user may be assisted, or urged, or expected, to move tip 108 at a certain speed.
20 The speed may be, for example, absolute, or relative (e.g., requiring a uniform speed or the

speed to match a non-uniform profile).

Optionally, an angular trajectory is defined, which places constraints on an angular

orientation of tip 108. In some embodiments, the constraint is one dimensional. In others it is

two or three dimensional.
25 Speed, angles and spatial trajectories in a particular rehabilitation scenario may each

belong to a different one of the above motion types. For example, spatial trajectory may be of a

force field type, while speed trajectory is free or assisted. The type of trajectory and/or its

parameters may also vary along the trajectory, as a function of time and/or as a function of

previous performance. For example, a smaller assistance at a later part of a trajectory may be
30 provided for a type of motion which was properly (or better than expected) executed in an

earlier part of the trajectory.

Trajectories may be absolute, for example, defined as a function of a resting point or a

different point on device 100. In other embodiments, the trajectories are purely relative, for

WO 2005/074373 PCT/IL2005/000142

example, requiring a patient to move an arm in a straight line, regardless of starting point. In
other embodiments, a trajectory is partially relative, in that once motion starts, this determines
the shape of the rest of the trajectory, for example, a start of a trajectory indicating if a patient
is standing or sitting, and thus what type of hand motion is expected.
5 In some embodiments, such as described below, where multiple points 108 are defined,

the motion types of each point may be of different types. In some embodiments, what is
defined is a trajectory as a function of two or more points in space. For example, if two points
are used to define an elbow configuration (e.g., angle between bones), the trajectory constraints
may be defined on the motion of the elbow. Such motion may be relative in space (e.g., a

10 comparison of the two points) and not absolute (e.g., compared to a device reference point). In
another example, different limitations are provided for different points, for example, angular
limitations at one point and velocity limitations of another.

It should be noted that in some embodiments of the invention a tensor or tensor field is
provided, as each point in space can have associated with it a speed, a force and/or a rotation,

1 5 all of which can be scalar or a vector.

In some embodiments of the invention, different modes are defined for different parts
of a trajectory or for different parts of space (e.g., for a particular arm). Optionally, a mode
may be triggered based on the actual performance. For example, if motion velocity is below a
certain threshold, a more assistive mode is provided. Similarly, a pause of over a threshold

20 may imply a more assistive mode. An exact motion may imply a less assistive mode.

In an exemplary embodiment of the invention, modes may be changed automatically,
for example, when nearing a patient motor limit (e.g., range of motion) or when nearing a
cognitive limit (e.g., spatial neglecting zone or time neglect zone such as for long motions).
Exemplary Usage

25 Fig. 4A is a flowchart 400 of a method of using device 100, in accordance with an

exemplary embodiment of the invention.

At 402, device 100 is powered on (for electrical devices). Optionally, device 100 turns
on when arm 102 is touched or moved a certain amount. Alternatively, motion of arm 102 may
provide power for device 100.

30 At 404, if remote connection 120 is used, device 100 optionally downloads

instructions, for example what activities to suggest and/or what progress was expected and/or
results from physical therapy at other locations. Optionally, a patient identifies himself to
device 100, for example, using a code, selecting a name form a list or using a smart card or a

WO 2005/074373 PCT/IL2005/000142

magnetic card with user input 118. Optionally, rehabilitation information of a patient is stored
or indexed on such a magnetic card or smart card or on a portable flash memory device or
portable hard disk.

At 406, an activity to be performed is selected. In a more automated device, the
selection may be, for example automatic or by a patient from a displayed list of options. In a
less automated device, for example, a patient may follow a chart provided to him by a
rehabilitation center or by a guiding therapist.

At 408, arm 102 is optionally moved to a start position thereof, for example by device
100 or by the patient (e.g., directly or by permitting device 100 to do so). It should be noted
that in some trajectories no start position is predefined. Instead, the actual starting position is
used to define the rest of the trajectory.

In some embodiments of the invention, the position of the patient relative to the system
is indicated or measured (e.g. by vision system, by mechanical attachments) and the program is
adjusted accordingly.

In some cases, device 100 is adjusted in another manner. For example, a particular
handle may be attached at tip 108, or legs of the device may be raised or lowered. In a
collapsible device (e.g., folding legs), the device may be set up. Optionally, such setting up is
carried out before activating device 100.

At 410, an optional warm-up session is carried out on the patient, to ensure that he is
ready for the activity. Optionally, one or more physiological sensors, for example a muscle
temperature sensor (e.g., skin surface) are used to ensure (e.g., as a safety feature) that the
patient is sufficiently warmed up.

At 412, the patient is optionally tested to confirm an expected current ability.

At 414, the results of the test are optionally used to modify one or more parameters of
the selected activity or to select a different activity, for example, due to an under- or over-
achievement of the patient during testing. Exemplary modifications include: slowing down
expected speed, reducing expected or resistive force, reducing expected or allowed range of
motion and reducing number of repetitions.

At 416, the activity is carried out, for example, continuous passive motion at 20
repetitions or motion (by patient) with resistance of 0.5 Kg, along the entire trajectory. In
another example, the resistance grows as a function of speed, or if the speed is higher or lower
than a defined speed trajectory, optionally using a mode or combination of modes as described
above.

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At 418, various measurements which are optionally made during the activity, are
optionally logged. Such logging may also be carried out concurrently with the activity.

At 420, feedback may be provided based on the activity, for example, to the patient, a
rehabilitation expert and/or to device 100. Optionally, feedback is provided on a patient
5 physiological condition as well, for example, determining fatigue based on increased
irregularities of motion and/or based on pulse rate or other physiological parameters.

At 422, a decision is optionally made to repeat an activity and/or to select a new
activity. Such a decision may be made, for example, based on patient progress and/or fatigue.

In an exemplary embodiment of the invention, device 1 00 automatically generates CPT
10 codes or other reports used for billing. Alternatively, a report is generated which a human
therapist approves and/or modifies. In some embodiments of the invention the patient's
progress is used to assess future expected payments and/or exercises and/or suggested human
guidance. Optionally, such future factors, patient improvement, time elapsed and/or motivation
of the patient in using and improving using the system, are used to decide on future financial
1 5 support by a health care provider.

In an exemplary embodiment of the invention, if after a given time (e.g. several weeks)
there is no improvement in function or other measurements a decision can be made to stop the
financial support. In another example based on documented improvement in certain areas (e.g.
patient accuracy) the treatment support can be extended. In another example, the therapy payer
20 may insist on minimum system usage (for example if a system was delivered to the patient
home). By reviewing an on going usage report (possibly on line) the payer can decide to
extend or stop usage.

In an exemplary embodiment of the invention, the system can simply generate codes
and/or reports, for example using a look-up table (each exercise can have an associated code)

25 using table and also automatically generate reports regarding other factors, such as motivation
and completion of plan.
Planning and Long-Term Progress

Fig. 4B is a flowchart 430 of a long term use of device 100, in accordance with an
exemplary embodiment of the invention.

30 At 432, a new patient who is identified as needing rehabilitation is tested, possibly

using device 100. For example, such tests may include range of motion tests, tests of
maximum applied force at different points in space, and/or tests of fineness of force control
and motion control. In an exemplary embodiment of the invention, device 100 calculates limb

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size (or detects them using a camera) and uses the limb size to adjust pre-stored exercises, for
example to adjust their trajectories and/or starting point.

At 434, the results of the tests are analyzed to determine the needs of the patient and to
formulate objectives of the rehabilitation. This act may be, for example, manual, automated or
5 manual with support from device 100.

At 436, a rehabilitation plan is drawn up, including, for example one or more of an
expected progress chart, various allowed and/or required exercises and exercise parameters for
different parts of the plan, definitions of increased and decreased difficulty levels for the
exercises, allowed and/or required exercise sequences, number of cycles for each exercise,

10 warm-up requirement, list of data to log, list of patient-modifiable information, one or more
safety parameters which should not be passed and/or one or more parameter alert values at
which an alert should be provided to the patient and/or a rehabilitation expect monitoring the
patient's progress. It should be noted that while generating a rehabilitation plan is a known
activity, in an exemplary embodiment of the invention, such a plan is special, for example,

1 5 taking into account one or more of the possibility of long term rehabilitation, the possibilities
involved in having a device available at a home for multiple short sessions, the provision of
multiple activities with a single device, the needs of remote monitors and/or the
programmability and responsiveness of a device in accordance with some embodiments of the
invention. The plan may be generated manually, automatically or manually with the assistance

20 of device 100, for example an initial plan generated automatically and then annotated or
approved by a human.

At 438, the plan is carried out, while being monitored. In an exemplary embodiment of
the invention, the monitoring is manual. Alternatively, at least some of the monitoring is
automatic.

25 At 440, the plan may be modified in response to the monitoring, for example, if slow

progress is detected, the plan time frame may be changed.

In some cases, as rehabilitation progresses, new problems may come up or become

emphasized. In some cases, the plan may be modified (440). In others, testing may be repeated

(442), generally to a lesser extent than when the patient was initially evaluated.
30 In some plans, periodic testing (for example on device 100 at the patient's home) is

part of the plan. Such evaluative testing may also be used to determine when rehabilitation is

complete.

At 444, rehabilitation is mostly completed and a training plan is optionally made, for

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example to ensure maintenance of the rehabilitation or for other reasons (such as prevention of
worsening or prevention of limb or joint neglecting).

At 446, long term monitoring of the patient may be performed, for example, testing the
patient's abilities once a week or once a month.
5 At 448, new needs of the patient may be identified, for example based on the

monitoring or based on a periodic general test. In one example, a patient being rehabilitated for
stroke may be determined after a time to need rehabilitation for a progressing arthritic
condition. In an exemplary embodiment of the invention, a personal profile is created for a
patient. For example, such a profile may include a series of items to work on, for example

10 smoothness of motion, which can be tackled one by one over time or if a certain threshold
value is detected during testing (e.g., quality of motion went below a threshold).

As noted herein, a particular property of some embodiments of the invention is that
device 100 may be used over a wide range of situations, including long range treatment and
following a patient from initial rehabilitation through follow-up rehabilitation (e.g., to

1 5 maintain an ability) and diagnosis.
Scoring and Time Estimation

In an exemplary embodiment of the invention, the ability and/or progress of a patient
are scored. In an exemplary embodiment of the invention, such scoring is used as an aid in
deciding on the need and/or type of future rehabilitation. Alternatively or additionally, scoring

20 is used to monitor the effect of rehabilitation exercises and/or help select between exercises.
Alternatively or additionally, scoring is used to ensure that a patient's needs (e.g., personal
rehabilitation needs or need for balanced rehabilitation) are met. In an exemplary embodiment
of the invention, scoring is used to identify areas where progress was made and areas where
additional therapy or modified therapy may be needed, due to lack of progress.

25 In an exemplary embodiment of the invention, one or more of the following measures

are used to score a patient's ability and/or progress.

a) Motor scores may include one or more of Range of motion, time of motion, force,
smoothness, lack of tremor, degree of tremor, spasticity, muscle tone, accuracy, quality of
motion and/or force finesse (control of force, e.g. not breaking an egg). These may be defined

30 for a single joint or for a complex motion, for example for pinching between fingers, holding
in a hand, moving of an arm. In addition some functional scores may be used to e.g. - the
speed at which the patient can move a filled glass, and the ability to pick and place an object.

b) Cognitive scores may include one or more of coordination between motion (motor

WO 2005/074373 PCT/IL2005/000142

skills) and senses (e.g., visual, auditory), speed of reaction, % of successful task completion,
quality of completion, mistakes, planning ability, level of instruction complexity used (e.g
level 1 is a simple visual & auditory instruction such as a forward arrow on screen & audio
verbal instruction, while level 5 is a complex screen to motion interaction, such as following a
5 3D path as shown on screen).

c) Mental stores may include one or more of: successful task completed at patient
capabilities and/or pain envelope, measure of self work, amount of nudging required from the
system, consistency of use (e.g., at home).

In an exemplary embodiment of the invention, scoring of the patient is calibrated to

10 other patients, for example, using a database of similar injuries, or using scores of patients that
are being rehabilitated at a same time. Alternatively or additionally, scoring is carried out
between a healthy and a non-healthy limb.

In an exemplary embodiment of the invention, scoring is used as an aid in diagnosis. In
an exemplary embodiment of the invention, when diagnosing a patient, scores are generated

15 (e.g., by providing suitable exercises) for individual body part abilities and for general
abilities. In an exemplary embodiment of the invention, device 100 can analyze a patient's
abilities by generating experiments and then analyzing the results. In one example, device 100
tests whether a patient will respond better to one type of exercise or to another by generating a
series of exercises including both types of exercises. The results of the patient's performance

20 are then analyzed to extract trends which indicate which of a controlled variable had a better or
a desired effect on the patient. Optionally, a human therapist selects the initial possible
exercises. Alternatively or additionally, a human therapist determines what percentage of time
may be spent on such exercises. The scoring method or resolution may be adjusted by the
therapist per the patient condition for example, adjusting the accuracy of measurement or the

25 dynamic range of the score or the expected results (e.g., for qualitative measures).

In an exemplary embodiment of the invention, a patient may show an increase in a
muscle strength score but not show a corresponding increase in accuracy (correspondence may
be, for example according to a table or according to a previous trend of the same patient,
possibly with a same limb). In such a case, the exercise plan for the patient may be modified to

30 include more accuracy-focused exercises and fewer muscle building exercises. It is noted that
not all rehabilitation plans aim for concurrent improvement in multiple measures. In some
plans, one measure is focused on and once a desired improvement in that measure is achieved,
a different measure is focused on.

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In an exemplary embodiment of the invention, a score in progress is used to estimate a
time to reach a goal. Optionally, such estimation is based on one or more of the following
variables: motivation, innate ability and current disability. Optionally, innate ability is
estimated by tracking the progress. Optionally, a set of results and estimated times for different
5 situations are stored in a database and used to generate an estimate. Optionally, a neural
network is used. Motivation is optionally estimated using methods as described below.
Alternatively, manual estimation may be provided. Optionally, a time estimation also includes
thresholds of different scores which must be met. For example, an estimate may be
conditioned on a certain motivation being maintained. Detection of a reduction in motivation
10 may be used to prompt an update in expected progress or suggest certain treatment.
Home Use

In an exemplary embodiment of the invention, device 100 is adapted for home use.
Such adaptation may include one or more of the following features:

a) Small size. For example, device 100 may take up less than 1 square meter of floor
15 space. Optionally, device 100 is sized to fit through standard door ways (e.g., of width of 60

cm, 70 cm or 80 cm).

b) Simple interface. In an exemplary embodiment of the invention, device 100 has a
simple interface to a user, for example including a small number of options to choose from,
graphical and/or speech instructions of use and/or feedback designed to be understand by a

20 typical adult. In an exemplary embodiment of the invention, a wired or wireless pendant or
wrist-worn controller is used. For example, such a controller can have a limited set of
commands, including, an exercise selector dial, a button for selecting a dry-run or a slow
version of the exercise, an activation button to start or stop an exercise, a scale or a pair of
buttons to increase or decrease exercise difficulty level, and a LED or LCD display for

25 feedback (e.g., red LED for bad and green LED for good). In an alternative embodiment,
device 100 is voice activated and controlled, for example using an IVR (interactive voice
response) type menu system.

c) Flexibility. In an exemplary embodiment of the invention, device 100 is designed to
be used by a range of different sized patients (or persons living in a home) and for a range of

30 different treatments, for a plurality of different body parts and/or appendages, for example, 1,
2, 3 or 4 limbs or body parts or more. In some cases, various attachments may be provided.
Optionally, device 1 00 is adapted for positioning at various orientations and/or in proximity to
home activities, such as at a table for rehabilitation of feeding and or activity of daily living.

WO 2005/074373 PCT/IL2005/000142

d) Lack of fixation. In some embodiments of the invention, device 1 00 is either simply
fixed to a surface or not fixed at all, simplifying installation and de-installation.

e) Mobility, detailed below.

f) Other home settings are optionally supported as well, for example, when the patient
5 is in bed, in the living room and/or in a backyard.

In an exemplary embodiment of the invention, device 100 is connected to home
appliances such as a TV or HiFi system. In an exemplary embodiment of the invention, the
patient can be instructed from the TV or the user can play with the system using the TV as
feedback. In another example, a set-top box is used as a local processor and/or a

1 0 communication port to a remote station.

In an exemplary embodiment of the invention, use is made of the fact that device 100 is
at home and conveniently located for the patient to use many times a day. In one example,
rehabilitation activities are designed to cover a larger part of the day than is possible at an
institute, for example, half or all of a day, while still allowing a patient to have a life with non-

1 5 rehabilitation activities. For example, a rehabilitation plan can call for ten 5-minute sessions
spread over an entire day, spaced by an hour.

In another example, device 100 interacts with real-life activities and/or using real-life
objects, as described in more detail below. In particular, this allows a rehabilitation plan to
show (and achieve) a real progress in the patient's ability to deal with real life situations, such

20 as eating and getting dressed.

In an exemplary embodiment of the invention, devices in separate houses are
interconnected, for example, within a family or between friends. Optionally, one of the
participants may interact using a computer, rather than a device 100 (e.g., using mouse
motions to emulate device manipulation, or as a player in a game using standard computer

25 interfaces).

In an exemplary embodiment of the invention, device 100 communicates with an
outpatient clinic so that home activities and clinic activities are synchronized. Optionally, the
patient carries a memory unit (e.g., a USB memory card) that includes his personal data.

In an exemplary embodiment of the invention, the home system generates reminders to
30 the patient to exercise, for example, audio reminders or e-mail or SMS reminders.
Remote Use

As noted above, device 100 is optionally used as part of a distributed system. Fig. 2
shows an exemplary distributed rehabilitation system 200.

WO 2005/074373 PCT/IL2005/000142

One or more homes with rehabilitation devices 100 are shown. A network 202, for
example an Internet, a cable network, a cellular network or a telephone network, connect
device 100 to a remote site. In an exemplary embodiment of the invention, a remote site is a
rehabilitation center including a computer station 204 with a display 206 and a user input 208.
5 A single station 204 can monitor multiple devices 100, optionally in real time. A plurality of
stations 204 may be provided, at a same or different sites. Optionally, a plurality of stations
204 are used to monitor a single device 100. For example, each device 100 may have a low
level monitoring by a semi-skilled person, who shows difficult problems to a skilled monitor
who is in charge of or associated with many unskilled monitored.
10 Also shown is an optional portable connection 212, for example using a laptop

computer.

Also shown is an optional remote database 210, which may store data for one or more
patients, for example, 100 or 1000 patients or more. While the database may be at the
rehabilitation site, this is not required. In some cases the database is distributed, for example,
15 among rehabilitation sites and/or user devices 100.

In an exemplary embodiment of the invention, a group of patients are collected into a
network based on them having similar (or overlapping) aliments, treatment and/or prognosis
and/or according to personal matching. In an exemplary embodiment of the invention, the
progress of members of the group are presented to other members, possibly spurring
20 competition. For patients with a lower motivation, a support group may be provided, for
example, one in which the patient is more advanced than other members or one in which a
group effort is being carried out instead of a competition.

In one example of a group activity, each of a plurality of patients has a role in a role
playing game. The difficulty of each patient/role may be set according to the patient's ability. A
25 group leader may be selected. In another example, each player is required to copy the
movements and/or instructions of the group leader. Optionally, each player is protected from
over-reaching his abilities by his device 100.

Other types of users may be supported in addition to monitors, for example, a patient's
general practitioner physician, or a family member or caregiver may be able to log on and
30 review a patient's progress.

Remote rehabilitation can follow several paths, for example, one or more of:

a) Real-time monitoring. Optionally, a camera 214 is provided adjacent device 100 to
allow a therapist to detect problems and/or give advice to a patient. Optionally, the data is

WO 2005/074373 PCT/IL2005/000142

analyzed by the therapist in real time. Optionally, a real time reconstruction with animation
software or VR (virtual reality) is used. Alternatively, off-line analysis is provided. Different
pay schedules may be provided for different types of monitoring. In addition, different
rehabilitation needs may indicate the level of interaction between a remote therapist and a
5 patient. Optionally, camera 214 is controllable by the therapist, for example to zoom and/or
pan to certain parts of the patient. Optionally, the path of the camera is pre-planned to track
planned or actual motion by the patient and/or of various points on a body of the patient.
Alternatively or additionally to camera 214, real-time monitoring may be provided by various
position and orientation sensors associated with device 100. This may also require only a

1 0 reduced bandwidth as compared to visual monitoring.

In an exemplary embodiment of the invention, a therapist can provide real-time
feedback, for example using audio-visual methods and/or by commanding device 100 to
respond in a certain way, for example, to increase force, to change a trajectory or to prevent a
patient going past a safety limit.

15 b) Live start. A rehabilitation session is started live (e.g., on camera) and once the

therapist is convinced the patient can work on his own, monitoring is stopped. Optionally, a
patient can request help, for example during an activity or between activities.

c) Planning. Plans including exercises and/or programming for device 100 are provided
by the remote site, for example, weekly, or at the start of each session. In some embodiments,

20 planning is automatic and optionally performed with or without patient input at device 100.

d) Monitoring. A remote site can specialize in analyzing data uploaded to it from
device 100 or another location and suggest changes. Other types of monitoring can also be
practiced, for example, checking to see how regularly a patient uses the system and/or for
following complaints. A rehabilitation center may perform, for example, weekly checkups and

25 possibly require periodic testing. Optionally, a patient may be called to come to the
rehabilitation center, for example, for testing, teaching and/or additional therapy.

e) Testing. In an exemplary embodiment of the invention, a remote site uses device 100
to administer tests to a patient and assess his condition and/or progress. In an exemplary
embodiment of the invention, such testing is used to assess the efficacy of drugs and/or other

30 treatment prescribed for the patient. Optionally, periodic testing is used to select a most useful
drug, for example, for a patient with Parkinson's disease or for a spastic patient.

f) Home therapist. In some embodiments of the invention, a therapist will come to the
patient's home for a rehabilitation session. For example, the therapist can set up device 100,

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mark correct starting positions, calibrate device 100 for the particular patient (e.g., size) and/or
teach the patient the use of device 100. Optionally, the therapist can access and/or be in contact
with a remote site, for example, for advice and/or monitoring of his work. When a therapist
comes for later sessions, the remote site may assist with comparing current and past
5 performance, for example. Optionally, a therapist brings device 100 with him. Optionally, a
therapist brings two devices. Optionally, a device brought by the therapist is used to control a
rehabilitation device already at the patient's home.

g) Remote maintenance. In an exemplary embodiment of the invention, device 100 can
be maintained from a remote location, for example, including one or more of reporting by

10 device 100 of technical problems; remote testing of mechanical abilities of device 100, with or
without patient assistance; remote testing of sensing abilities of device 100, with or without
patient assistance; downloading and uploading logs; and/or downloading and uploading
software. Optionally, device 100 collects billing information which is remotely accessed.
Optionally, device 100 collects usage information which may be used, for example, by an

15 insurance company. In some embodiments, remote access to device 100 is designed to
maintain a patient's privacy, for example by hiding patient identifying information, by limiting
access to various logs and records and/or using password and other authentication schemes.

h) Remote motivation session. In an exemplary embodiment of the invention, device
100 is used to detect a reduced motivation level and a live therapist (optionally provided at

20 need) can provide live encouragement and/or instruction. Live remote sessions in general may
be provided.

In an exemplary embodiment of the invention, virtual reality methods, for example
goggle mounted displays are provided at the remote location, to help the remote operator feel
in better control. Alternatively or additionally, the operator can manipulate his viewpoint. In an
25 exemplary embodiment of the invention, various sensors (for example as described below) are
used to move a model of the patient, for remote and/or local feedback.
Other Usage Scenarios

Device 100, in some embodiments thereof may be used in other ways than described
above. For example, in one embodiment of the invention a supervised group is provided, in
30 which one or more therapists watch/monitor/support a plurality of patients, each on a different
device. In such a supervised group, one or more of the following scenarios may be acted out:

a) Bring along - a therapist brings a plurality of devices 100 to a civic center or old age
home or the like, and teaches a session to a group of users.

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b) Game - each patient plays a part in a game and a score is kept. In the example of an
adventure game (e.g., a role acting game), patients can earn life points, weapons, abilities and
other items by improving their abilities using rehabilitation exercises. The game may be
personally adapted to one or more patients, for example by providing assistance to those

5 patients who require it. In an exemplary embodiment of the invention, the games require a
patient to carry out certain physical activities. The activity may vary between patients
according to their needs for rehabilitation. VR or simpler display technologies, such as screens
may be used to help patients become immersed in the game and focus less on the other players.
Such games can be played also when the patients are distributed and interconnected by a
10 network, such as the internet.

c) Call-in group - the patients can join an existing group or game or session, to form a
virtual "therapy room". Optionally, a chat line is provided concurrent with the rehabilitation
exercises. Optionally, a rehabilitation server is provided for devices 100 to connect up to and
register requirements, obtain connections to other devices and/or control access to a therapist.

15 In an exemplary embodiment of the invention, a group is supervised by a therapist and

the therapist can monitor the group using a web cam, for example. Alternatively or
additionally, patient's exercises can be reconstructed on the therapists system using VR or
simulation. Alternatively or additionally, the therapist can review data generated by the system,
such as scores. Optionally, different levels of interaction between the therapist and patients can

20 be provided, for example, based on payment plan. In one example, a live connection is
available to only higher paying patients. In another example, a web-cam interface is available
only to higher paying patients. Similarly, the payment plan may dictate other parameters of
treatment, for example, complexity of exercises, level of review, interaction between patients
and quality of audio visual effects and/or games. Optionally, the amount of rehabilitation

25 actually provided by the system also depends on the payer. Alternatively or additionally, the
payer is billed according to the rehabilitation performed.

d) Test and/or train - In an exemplary embodiment of the invention, the group is used
by the therapist to try out new therapy ideas and receive feedback form the patients, in real-
time on the relative benefits and problems with different methods. Optionally, such a group is

30 used for training purposes, for example to allow a therapist to view multiple patients at same
and/or different conditions, substantially simultaneously. Optionally, if differences are
identified, the therapist can be trained to detect such differences and/or be shown how to
differentially rehabilitate for them.

WO 2005/074373 PCT/IL2005/000142

In an exemplary embodiment of the invention, a linked-system scenario is carried out.
In one example, two devices are connected using a master-slave relationship for example using
a wired or wireless (e.g., BlueTooth, Cellular or WiFi) connection between them, or using a
network connection between them. A master can be, for example, a son (or daughter) and the
5 slave is an aged parent whom the son is assisting in rehabilitation. This allows a paretic parent
to use the rehabilitation exercises as a means for maintaining contact with the family.
Alternatively or additionally, the paretic parent may receive support from family members.
Such support may also include advice on how to use the system and/or on what exercises to
try.

10 Another exemplary usage of linked devices 100 (or a single device with multiple arms

102) is for child play. In an exemplary embodiment of the invention, a paretic child plays with
a healthy child, each child manipulating a separate arm or device. Optionally, the motor
abilities of the paretic child are compensated for by device 100, for example, providing speed
enhancement or providing periodic automated action. If the children play a role-playing game

15 or a sport simulation (e.g., tennis), device 100 can supplement the abilities of the paretic child,
while still allowing the child some control over the game, for example, allowing the paretic
child to actually perform 20% of the moves. Device 100 can control the level of support for the
paretic child to ensure a level playing field.
Feedback and Patient User Interface

20 Various types of feedback are envisioned for use with exemplary embodiments of the

invention, for example, one or more of:

a) Feedback from a patient. Optionally, a patient can provide feedback to a therapist,
for example, using voice annotations or text annotations. In one example, such feedback is
provided during an activity. In another example, a patient reviews a recording of the activity

25 and then adds comments. In some activities supported by exemplary embodiments of the
invention, a patient is requested to manipulate a control, when a certain situation is reached,
for example, a maximum force. Feedback may also be provided by the patient for a plan or
progress, not only for individual activities.

In some embodiments of the invention, patient feedback is processed by device 1 00 to

30 modify and/or decide on current or future activities and/or their parameters. For example, if a
patient marks that a certain force is a maximum force, later activities will not pass that force.
In some embodiments of the invention, no explicit user feedback is required, instead, the
system can implicitly determine when a maximum force is approached, for example based on

WO 2005/074373 PCT/IL2005/000142

difficulty in control, and model future activities on the thus determined force.

b) Feedback to patient. In an exemplary embodiment of the invention, feedback is
presented to a patient, for example, during an activity, in rest breaks and/or after an activity.
For example, such feedback can include an indication to the user that he is performing an
5 activity incorrectly, that future cycles should be done differently and/or a comparison between
current and past performance and/or other statistics. It should be noted that in many cases
positive feedback is as important or even more important than negative feedback. This may
depend on the rehabilitation method used. A positive feedback can be, for example, an
auditory encouragement, a sound of clapping hands, a visual pleasing screen and/or a score
10 increase.

Various feedback modalities may be provided, for example, speech and audio
feedback, a display containing text or graphics, a marked up video image, force or vibration
feedback on device 100 (e.g., by tip 108), using a separate element (such as the above pendant)
and/or using virtual reality devices, such as goggle mounted displays, in which the type,

1 5 position and/or other parameters of a mistake (or correct action) are shown overlaid on a real
or virtual image of the activity.

As described, for example, in U.S. Provisional Application 60/633,429 filed on
December 7, 2004, also being filed as PCT application on same date as the present application
and by the same applicant, entitled "Rehabilitation with Music" and having attorney docket

20 number 414/04396, the disclosures of both applications are incorporated herein by reference,
the disclosure of which is incorporated herein by reference, music may be used as a feedback
modality, especially for patients with limited cognitive speech and/or visual ability. For
example, music can be used to indicate a quality of motion, be generated by the motion or be
used by device 1 00 as instructions or cues to the patient.

25 c) Feedback to therapist. In an exemplary embodiment of the invention, a local or

remote therapist is provided with feedback. Such feedback can include, for example, one or
more of extent of use (e.g., including whether patient is exercising when therapist is not paying
attention), force levels, an indication of mistakes, a notification of missing, exceeding or
meeting certain parameters, a predefined alert, a motion quality (described below) a safety

30 situation and/or a statistical analysis of a current and/or a past activity.

d) Feedback from remote therapist. In an exemplary embodiment of the invention,
feedback is provided by a remote therapist, for example as indicated above of feedback that a
patient may receive. Optionally, such feedback includes instruction to device 100 whether to

WO 2005/074373 PCT/IL2005/000142

repeat a certain exercise and/or modify parameters. In an exemplary embodiment of the
invention, an exercise is defined with, or a therapist can add, break points, at which the
therapist, patient and/or device 100 (depending for example on implementation) can decide,
for example, if to modify future parameters, impose a rest and/or repeat an activity if a desired
5 result was not achieved. Such a breakpoint need not be notice by a patient, if no decision is
made by him and a decision is made fast enough or during a short, pre-defined, break.

e) Feedback from device 100. Depending on the automation level of device 100,
feedback can be provided by the device, for example indicating a threshold was past or
indicating a safety problem.
10 f) Feedback from sensor patches attached to or image based analysis of the patient

and/or device 100. Exemplary such patches are described below with reference to Fig. 5.

g) Feedback from one device to another, for example, in a master-slave mode of
operation.

In an exemplary embodiment of the invention, speech is part of the rehabilitation
15 process. In one example, device 100 responds to or expects voice commands. In another
example, device 100 generates voice instructions.

Simple interfaces may be required for some users. In one example, instructions to a
user (patient) are simple red/green lights, to indicate go and stop.

A plurality of different types of cues may be provided to indicate a need to act by the
20 patient, for example, audio, tactile, vibration (of device 100 or of a patch), motion of opposite
limb, visual (e.g., flashing screen) and/or change of speed. In an exemplary embodiment of the
invention, a jolt, for example an audio blast (or shout) is used to alert an otherwise non
responding patient, for example.

In an exemplary embodiment of the invention, a dummy body is used to show the
25 patient the effect of the motion of device 100 (e.g., arm 102) on the patient.

Optionally, the complexity of the interface used increases as the patient rehabilitation
progress and the patient's cognitive abilities improve and/or the patient has more attention to
spare. Optionally, for example as described below, the user interface is used for performing
concurrent cognitive, perceptive and motor rehabilitation, for example, by selecting the
30 interface used to match an ability of the patient and/or train the patient in certain non-motor
activities.
Mental state

As noted above, the progress of rehabilitation of any particular patient typically

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depends on one or more of the following: cognitive ability (if the patient cannot think clearly,
motor planning is difficult or impossible), mental ability (if the patient has no motivation,
rehabilitation is difficult) and motor capabilities.

In an exemplary embodiment of the invention, one or more of these may be measured
5 and/or supported by device 100. Optionally, changes in the degree and/or type of support are
determined by system 100. Alternatively or additionally, changes in support are determined by
a user, or a plan of how to change support according to scores, is set by a user.

Support of cognitive abilities is, for example, by providing a simple display, multiple
modes of presentation of information, reminders and/or multiple cues. Cognitive abilities may
10 be tested, for example, by providing tests or by assessing performance in games where
cognitive ability is required. In some cases a distinction is made between cognitive abilities
and perceptive abilities.

In an exemplary embodiment of the invention, the patient is required to execute a
motor task (e.g. move forward) his ability to understand the task depends on the cognitive
15 capabilities. The ability to see a target on the screen or actually receive the instructions (e.g.,
visual or verbal) depends on his perceptive abilities.

Support of motor capabilities is, for example, by the various modes of motion
described above. Measurement of motor capabilities is, for example, by providing exercises
having a standard range of results and placing the results on a known scale.
20 In support of the mental state, various methods are provided herewith in some

embodiments of the invention:

(a) Device 1 00 (or a remote controller) can supply the initiative instead of the patient,
for example, initiating motions and initiating exercise repeats.

(b) Device 100 can provide incentive, for example, scores, special feedback elements,
25 such as images, jokes, funny icons, laughter and/or rest periods.

(c) Device 100 can support groups, where members of the group provide motivation for
each other, for example, via cooperation and/or competition.

(d) Device 100 can provide games.

(e) Device 100 can indicate a lack of motivation which suggests a need to provide
30 consoling.

(f) Device 100 can increase patient motivation and reduce fear by presenting safety
features and/or features design to reduce pain (e.g., a user indicating a pain range and device
100 ensuring that the pain range is exceeded only when the patient is forewarned). In an

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exemplary embodiment of the invention, a user indicates a pain range to device 100 by
pressing a control when a pain point is reached or by a therapist doing so. Specialized pain
sensors may be used as well, for example, detecting nerve activity or detecting physiological
changes such as sweating or increased pulse.
5 (g) Device 100 can selectively provide positive feedback or negative feedback.

(h) Device 100 can be set to more or be less forgiving of errors.

(i) Device 100 can track which exercises seem to inspire more motivation and/or
cooperation from a patient.

(j) Device 100 can provide attention instead of a patient, for example, continuing
10 attention to ensure that a motion once started is carried out. If a mistake occurs, instead of the
patient being required to notice it, device 100 can detect the mistake and provide a cue to
correct the motion - thereby reducing the mental and cognitive load on the patient.

While motivation and other mental states such as depression and withdrawal may be
estimated by a human, in an exemplary embodiment of the invention, they are measured or
15 estimated by device 100 by detecting their effect on performance. In an exemplary
embodiment of the invention, device 100 assesses, for example, one or more of: how hard a
patient works, how well the patient carries out his task, progress within and between sessions,
expected responses to stimuli and/or variability between different tasks and/or along a task.

In one measurement method, a patient's performance on a task is compared to the
20 patient's performance (e.g., range of motion, speed accuracy) in a game. Under the assumption
that playing a game increases motivation, differences in performance between a game and an
exercise, may indicate the degree of motivation difference between desired and undesired
tasks.

In another measurement method, device 1 00 is used to measure the range of a patient's
25 abilities, for example, ROM (range of motion), pain limit and the like. It is assumed that a
diagnosis session can be trusted to provide relatively accurate information about the patient's
ability, at least for the reason that the patient knows the diagnosis session is limited in scope.
Thereafter, exercises at the edge of the patient's ability are provided to the patient and a
determination is made of the number and success of attempts to reach the edge of the range.
30 This determination may be used as an indication of motivation (e.g., willingness to achieve
what is known the patient can achieve). In an exemplary embodiment of the invention, the
exercise comprises providing performance targets to the patient and the patient is expected to
reach for the targets.

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In another measurement method, a self-calibrating method, a patient plays a game in
which some of the targets are at the range of the patient's ability. As this ability might not be
known in advance, a variety of targets of different levels of difficulty, are provided. In an
exemplary embodiment of the invention, motivation is assessed by analyzing the game to
5 determine, first, what the patient's abilities are and, second, how often the patient tries to reach
the edge of his abilities.

Another method of measurement is tracking how hard a patient works (e.g., how long
are rest periods). Another method is determining the hardest a patient works in any particular
exercise. Another method is determining if a patient provides attention, involvement and/or

10 activity in a free-play session, where a patient can exercise if he wants to, to any degree of
difficulty the patient wants. Attention is optionally determined by comparing trajectories of
motion at different times, for example to see the range of variability (e.g., does a patient
suddenly slow down - maybe his attention wandered). Involvement is optionally determined by
tracking modifications requested by the patient, for example in exercises where a patient can

1 5 select one of several trajectories.

In an exemplary embodiment of the invention, mental state is estimated by analyzing
handwriting or gross motor movements, for example, detecting unusual tremors, ticks or other
signs of tension and/or lack of control (e.g., as compared to other times). It should be noted
that mental states, in some cases, may be provided as a relative state rarer than absolute values.

20 Exercises

In an exemplary embodiment of the invention, existing physical rehabilitation exercises
are used for device 100. However, various measures can be provided not currently available. In
some cases, the exercise is modified to take into account limitations of device 100 or abilities
of device 100. Optionally, correct motions are determined with exactitude and/or with a degree

25 of control not possible manually. In addition, some exercises are described herein which are
not possible without robot support (or other techniques described herein).

In an exemplary embodiment of the invention, exercises are modified manually. In an
exemplary embodiment of the invention, exercises are recorded by a therapist and then
annotated (e.g., to mark desired measurements). In another example, exercises are directly

30 programmed into device 100. Optionally, device 100 suggests limitations or additions to
exercises, for example, safety limitations or device limitations and/or suggest where a less
supportive or more supportive motion mode may be appropriate (for example at an end of a
motion a more supportive mode may be advisable).

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In an exemplary embodiment of the invention, a reaching exercise is performed by the
patient. In such an exercise, various muscle groups can be trained and various levels of
difficulty can be provided.

In an exemplary embodiment of the invention, reaching movements are defined by one
or more of the following exemplary parameters:
Reach Distance:

Close - touching the body or several inches from the body
Mid - in the mid range from full to close
Far - almost at full arm extension
Reach Direction:

Up/Down - from a lower/higher reach location to a higher/lower location
Out/In - moving away/to the body

Lateral/Proximal - moving out from the body laterally/moving toward the body
Reach height:

Above head

Eye level

Shoulder level

Torso level
Reach target:

Free reach - movement to general location in space with no target
Target reach - movement to a physical target

Simulated target - movement to a target presented on a computer screen
A particular "Reach" is defined by the starting location and the ending location of the

hand as defined by its distance, direction, and height. Any reach may also be further

understood in terms of the involvement of the arm joints and the ability of the patient to

individuate the joints to achieve the reach.

In an exemplary embodiment of the invention, one or more of the following measures

is defined:

Ability of the patient to perform the reach;

Smoothness of motion;

Time to achieve the reach end point;

Accuracy of the reach;

Work or power performed;

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Comparison of motion trajectory to normal trajectory patterns for reach movements;
Number of repetitions of the reach the patient can perform;
The stability of the performance with subsequent repetitions.

In an exemplary embodiment of the invention, a reach training comprises the following
5 general steps:

5 to 10 repetitions to reach under guided motion. Patient will be instructed to attempt to
move with the device 100.

5 to 10 repetitions initiate mode. The magnitude and direction of force of the patient
will be measured by device 100. When the threshold for correct intention is exceeded, device
10 100 will guide the patient to accomplish the reach.

5 to 10 repetitions assisted mode. The patient will attempt to perform the reach
independently. Device 100 will measure the intention and assist the patient to move. Over
time, the amount of assistance will be reduced as the patient is able to move more
independently.

15 5 to 10 repetitions of free motion. Patient will attempt to perform the reach free of

assistance from device 1 00.

Another exemplary exercise is mimicking of daily activities, such as moving a full cup
between points and lifting a book.
Programming

20 In an exemplary embodiment of the invention, various aspects of a rehabilitation

process can be planned and inputted as instructions to a computer (e.g., device 100), including,
one or more of:

a) designing a new exercise;

b) modifying an exercise for a particular situation and/or patient;
25 c) designing and modifying a rehabilitation plan; and

d) designing and modifying decision logic (e.g., breakpoints, thresholds and
repetitions).

Permissions may be different for different users of system 200 and/or device 100, for
example, different permissions may be allowed for one or more of adding new, copy, modify,
30 delete and/or edit. These activities may apply, for example, to one or more of patient data,
activity, plan, statistics and/or data logs. Particular activity parameters which may be created
and/or modified in accordance with exemplary embodiments of the invention include:
trajectories, locations and ranges (e.g., minimum and maximum speed and angles); force

WO 2005/074373 PCT/IL2005/000142

parameters, number of repetition cycles, stop decision(s) and/or rest periods length and
frequency.

In some embodiments of the invention, one or more libraries are provided as a basis for
modification and for storing programs, for example, a plan library, a per-patient library and/or
5 an activity library.

In an exemplary embodiment of the invention, entering a new trajectory is by
physically manipulating tip 108 (e.g., by a patient with a good hand or by a therapist).
Optionally, the resulting trajectory(s) are then edited on a computer. Alternatively or
additionally, a 3D CAD/CAM program may be used, optionally one in which a human body is
1 0 modeled and various constraints can be placed on movement of points on the body and/or a
desired or allowed range of motion for such points defined. Optionally, a graphic design
program is used, for example, with a user indicating a few points of a trajectory and the
program completing them with a line or a curve. Alternatively or additionally, a user may
define various geometrical shapes, such as a circle, for example by providing points and/or a
1 5 formula. Alternatively or additionally, a user may make a drawing and scan it into system 200
(e.g., at a station 204 or at device 100).

In an exemplary embodiment of the invention, an exercise is calibrated for a particular
patient and/or situation. Such calibration may include, for example, one or more of:

a) calibration to patient abilities, such as angular range of motion of a joint or ability to
20 apply force or maintaining fine positional control;

b) calibration to a size of a patient, for example, the length of a limb or a bone;

c) calibration to progress, for example, a plan may have its time span and/or its step
size changed based on exhibited or expected progress.

As noted above, a path carried out by a patient or by a therapist may be edited and used
25 for an exercise. In an exemplary embodiment of the invention, editing includes one or more of
smoothing, adding points and/or path sections, converting the motion into primitive motions
elements,

Exemplary programming language

Table I, below, describes an exemplary high-level programming langue which is
30 optionally used to program device 100, in lieu of learning a robotic programming language. In
an exemplary embodiment of the invention, this language is used by the therapist and/or other
user. Optionally, existing exercises are storable and modifiable.

This high-level language is based on library of Icons (each representing a command)

WO 2005/074373 PCT/IL2005/000142

that can be draged into a program area in order to build (or edit) a program. Each icon
represents a command; with 3 types of command defined (more may be added):

a. Motion command - basic motions, such as line and circle. Each command has start
point (PI) and stop point (P2), for every motion command the speed, force
acceleration/deceleration time can be set. Setting the points (PI, P2) can be done by pressing
the enter key while tip 1 08 is at the desired point.

b. General command - such as start/stop program, delay and record.

c. Accessories command - a set of command that handle the external devices and
accessories that can be attached to device.

Every command has a set of parameters that may be entered (if not, a default parameter
value may be used). An operator can add comments to each command. Device 100 generates a
description for each command., to every command the operator can add comments, and every
command has a description. Not shown are commands for instructing users and parameters
which define what behavior device 100 should carry out under certain conditions. Optionally,
each path section may include one or more triggers, which, upon activation, execute short
sections of code. One example is a trigger activated when a user varies his speed more than

10%, in which case a warning is provided or a more assistive motion mode is provided.

Motion

Line
Curve

Left
Left

pl,p2, F , S,Text
pl, P 2,p3,F,S

Press @ PI &
press @ P2
Use PI to start P3
as end & P2 as
Via point and
curve

F- force S -
Speed

system
interpolates

commands

Circle/
ellipse

Teach
points

Left
Left

C,Rl,R2,F,S,Tex
torPl,P2,P3

Pl..Pn,F,S,Text

system
interpolates
between points

For ellipse use
R2 not 0

Teach Path

Left

Path,F,S,Text

System samples
path

sample rate

Genei

Start

Both

Text

first program
command

al commands

stop
Delay/Pause

both
Left

TXT- Text

T-Time (second)
or B- (button
name); TXT

end of program

can be used for

waiting on
certain button
press

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PCT/IL2005/000142

N; No. Of

repeated cycles;

allow to disply

Cycle

both

TXT

3 level data
accuracy: Normal

Position,
force,speed,
acceiarauon,,jerK,
I/O state,
preload,brake

No. Of cycles
Indicate record

Record

right

Fine coarse

setting

mode on/off

analysis

right

use M eval" command, for example

logic may be

Read (string);

use as input

used with if

read input

both

TXT

mechnism

input

Handle 1 pinch

Handle

(on/Off, force

pinch/grip

n
ft

pinch

range(kg/Lb))

handle

Handle 1 grip

right

(on/Off, force

pinch/grip

Handle grip

range(kg/Lb))

handle

mniand

wrist

Handle wrist

motion

3Xrange of force

wrist handle

elbow

Table I: command types

Table II is a sample program, using the language shown in table I. A program structure
has several columns; the first one is the main command that are sequential, the second and
third columns are for commands which operate in parallel.
5 When a new program is started, the start and stop commands optionally are provided

automatically. Other commands are manually inserted between the start and stop.

Table II is a sample program of a path having 3 straight lines (can be rectangular), with
a delay in between, and during the second line an external device is operated (for example -
waiting for input from handle). All data during the second and third lines is recorded and the
10 entire program is repeated 5 times. Modifiers for the repetition (e.g., increase speed, increase
required accuracy) are optionally provided as parameters. General program parameters, such as
type of scoring, expected quality of motion are optionally provided as well.

Prog name

description

date

file name:

triall

glass grip

auto date

xxx.prg

WO 2005/074373 PCT/IL2005/000142

Commands

optional
command

Parameters

comments

start

line

PI (start
point) P2
Force
(PA[VALU
E] / PP)

PA (value) patient

\ /ST

active must exceed
force value ; PP Patient
passive - no force value

delay/pause

D(lsec)

handle pinch

record

1 kg<force
<5kg

display grip force
during run if not in
range display warning
message

line

handle pinch

record

PI P2 Force (PA[VALUE] / PP)

delay/pause

handle pinch

record

D(lsec)

line

record

PI ,P2(start point)

cycle

record

N = 5

stop

Table II: program sample

A particular type of control provided in accordance with some embodiments of the
invention is spatial programming control. In this type of control, certain gestures or positions
in space of tip 108 are translated into commands for device 100. In one example, such gestures
5 may be used by a therapist or by a patient to fast forward past an exercise section.

In another example of a shortcut, wrist movements of a therapist will be translated into
arm (or other limb) motions, thus allowing the therapist to make smaller motions and only
with his hand, rather than the limb whose motion is being programmed.
Sensing and Control of Limb Position
10 In device 100, as illustrated, only one point of the patient is controlled, the point in

contact with tip 108. However, this means that multiple different arm motions can result in a
same spatial trajectory. For some situations this is not a problem. For example, for recovery
from stroke, in some cases, any motion is useful. In other rehabilitation scenarios, it is
desirable to better dictate or know the positions of all the moving body parts. In some

WO 2005/074373 PCT/IL2005/000142

exemplary embodiments of the invention, the position of other body parts is fixed. For
example, a patient may be strapped to a chair (e.g., the shoulder of the patient) and/or a rest
may be provided for an elbow. This restricts possible motions by a hand holding tip 108.

Fig. 5 illustrates a system 500 including limb position sensing and/or restricting, in
accordance with an exemplary embodiment of the invention. Correct motion of other parts of
the body than the hand that contacts tip 108 may be provided, for example, by detecting the
positions and providing feedback, for example, audio or visual feedback, to the patient.

A patient 506 sits in a chair 514 and uses device 100 (or a device as described below in
which the arm is mounted on a ball). One or more cameras 502 image the arm and/or other
parts of patient 506 and determine the spatial position and/or velocity thereof. Alternatively or
additionally, one or more cameras 516 are mounted on device 100 for such imaging. In some
implementation of image based reconstruction of body positions, it is useful to include one or
more fiduciary markers 504, for example strap-on patterns or LEDs.

Alternatively to image based position sensing, magnetic, electric, ultrasonic or other
contact-less position sensing and orientation sensing methods may be used. Many such
position determination methods and devices are known in the art and may be used. In an
exemplary embodiment of the invention, a reference position is provided on device 100 and/or
on tip 108. Optionally, such position sensors are used for determining the state of device 100,
instead of or in addition to mechanical sensors in device 100.

Alternatively or additionally to using contact-less position sensing, mechanical based
position sensing, for example using an articulated arm, may be used.

It should be appreciated that in some embodiments of the invention no arm 102 is
provided, instead position sensors of some type are used. Feedback is optionally provided via
virtual reality type displays and feedback (e.g., vibration to emulate force). However, this may
not allow direct force feedback and resistance to be applied, as desired in other exemplary
embodiments of the invention.

In an exemplary embodiment of the invention, patches 504 are used to provide
feedback or cuing to a patient. In an exemplary embodiment of the invention, a patch includes
a wireless receiver, an optional power source and a stimulator, for example a vibrator, pin-
prick, a pincher or a heating element. Upon command from device 100, patch 504 can provide
a stimulation to the patient. Patch 504 may be wired instead of being wireless.

In an exemplary embodiment of the invention, sensed positions of body points are used
for one or more of:

WO 2005/074373 PCT/IL2005/000142

a) determining if a body motion is correct;

b) determining what motions are possible (e.g., based on angles of joints);

c) learning desired motions from an example;

d) monitoring a patient's ability (e.g., for testing or limb measurements); and/or

5 e) determining if a body posture is correct during, before and/or after exercise and

when changes occurred.

Alternatively or additionally to position, orientation and velocity sensors, physiological
sensors may be provided, for example one or more of pulse measurement sensors as known in
exercise machines and grip and/or pinch force sensors in tip 108. Alternatively or additionally,
10 one or more physiological sensors may be provided on the patient, for example, breath rate
sensors.

Referring back to Fig. 5, alternatively or additionally to position sensors, a body rest
508 may be provided for one or more body parts. In the example shown, rest 508, attached to
chair 514 by a (optionally adjustable) bar 510 prevents motion of the chest and/or shoulder. In

1 5 an alternative embodiment, one or more straps are used to hold body parts.

In an exemplary embodiment of the invention, reverse kinematics method are used to
estimate the motion and/or dimension of a patient's joints and/or bones. For example, if a limb
is fixed to rest 508, movement of tip 108 can be used to estimate the actual motion of the joint.
When harness 508 used to lock the elbow is in a fully extended position, the distance from the

20 shoulder to wrist can be calculated as the patient moves the arm. If the handle of Fig. 15F is
used and patient is restricted by a shoulder harness then the forearm length can be determined
Alternatively or additionally, a force field can be used to restrict the motion in a manner which
will guarantee that limb dimension can be determined.

In an exemplary embodiment of the invention, a model of the patient is constructed for

25 use in such reverse kinematics calculation. Also, in safety calculations, such a model may be
used. For example, a motion may be prevented as being unsafe if a patient can possibly reach a
configuration of joints where the motion is unsafe. The reach of each joint may be dependent,
for example, on fixation of the patient (e.g., harnesses), measured ROM and assumed ROM.

Optionally, chair 514 is fixed to device 100, possibly in an adjustable manner, for

30 example, using a fixation bar 512. Optionally, an initial calibration process is carried out, for
example when first doing a new activity or during device setup. In one example, bar 512
includes graduations and during calibrations the correct setting of the chair relative to the
graduations is determined.

WO 2005/074373 PCT/IL2005/000142

In some embodiments of the invention, device 100 comes with a built-in chair 514.
Exemplary positioning of a movable chair is described below.

In an exemplary embodiment of the invention, positioning sensing is to better than 1
cm, 5 mm, 2mm or 1 mm, over the entire working volume of the device. In some
5 embodiments, a lower absolute positioning accuracy is tolerated if a relative accuracy, within
an exercise is maintained.

In an exemplary embodiment of the invention, accuracy of force control is better then
100 gr, 50 gr, 10 gr or better. Optionally, the balancing of the arm is within these values.
Similar accuracies may be provided for measurement. Optionally, sampling rate of better than
10 10Hz, 50Hz, 100Hz or more is provided.
Patient positioning

In some embodiments of the invention and/or exercises, the patient position is not
important. However, in many exercises, correct targeting of a certain joint, tendon and/or
muscle group may require precision in motion of tip 108 relative to the patient and/or in the

1 5 posture of the patient and or other body part.

In an exemplary embodiment of the invention, straps, a harness and/or rest 508 are
provided to set the position of the patient. Optionally, one or more bars 512 links chair 514 to
device 100. Alternatively to a bar, reference 512 represents a spring-loaded wire, which
includes a position sensor to indicate its retraction and thus the position of chair 5 1 4 relative to

20 device 100. Optionally, a plurality of retractable wires are used. Optionally, each wire includes
a ring into which a leg of chair 514 is placed. Optionally, if the chair moves during a session,
the exercises are corrected on the fly to account for the new relative position of chair 514 and
device 100. Alternatively or additionally, if motion of the patient is detected during a session,
for example motion from one posture to another, the exercises are adapted to reflect the new

25 position. Optionally, a plurality of typical static postures of the patient are learned and the
system uses these learned postures to distinguish ongoing motion from semi-permanent
postures. Optionally, change in posture is detected by changes in pressure on various pressure
sensors, or using cameras which image the chair, device and/or patient. Alternatively or
additionally, changes are detected by detecting changes in the actual trajectory followed by tip

30 108.

Optionally, a mat 5 1 8 is provided. In one option, mat 5 1 8 is a pressure sensitive mat
for detecting positions of chair legs or patient legs. Optionally, calibration is performed for the
chair that the patient actually uses. Alternatively or additionally, the mat is used to allow

WO 2005/074373 PCT/IL2005/000142

manual entry of relative position. Alternatively or additionally, the mat includes markings that
are recognizable by a camera that images the mat.

In an exemplary embodiment of the invention, tip 108 is used to determine the position
of chair 514. In one example, once chair 514 is locked in place, tip 108 is used as a digitizer by
5 contacting points on chair 514 and/or the patient. In some cases an adaptor tip may be placed at
tip 108. Optionally, once a patient position has been digitized once (e.g., under therapist
guidance), next time chair 514 is brought to device 100, tip 108 is moved by device 100 to
indicate a desired position of chair 514 or the patient.

Optionally, a laser or light pointer is attached to tip 108 (or other part of arm 108 or
10 device 100) and serves to generate a light marking of a desired location for a chair and/or
patient part. Device 100 optionally converts between the coordinate systems of the pointing
device, arm 1 08 and/or chair.

In some embodiments of the invention, it is not tip 108 which has to be at a certain
position, but the patient's hand or finger. Optionally, a dummy hand is placed in device 100
1 5 and used for such calibration.

It should be noted that positioning methods as described herein may also be used for
positioning other parts of the rehabilitation system, for example, a table, a glass, a second
device 100 or a kit for daily living, for example as shown in Fig. 19H.

In an exemplary embodiment of the invention, patient positioning is determined by
20 patient kinematics. In an exemplary embodiment of the invention, once a patient is positioned,
the patient performs one or more exercises and the patient position is determined based on the
actual trajectories followed. In some cases, a previous ability of the patient, for example, joint
range of motion, needs to be known in order to determine the patient position.

In an exemplary embodiment of the invention, the patient performs swinging of the
25 arm, without bending the elbow. The radius of the motion indicates the position of the
shoulder joint. If the patient cannot straighten his elbow (or keep it straight) this information is
optionally used.

In an exemplary embodiment of the invention, it is assumed that patient movement
between sessions is mainly translational motion in a 2D plane, so only one motion of the arm
30 is sufficient for position calibration. Optionally, two arms are moved, to assist in detecting
body twist.

Optionally, alternatively or additionally to determining patient position, an initial set of
patient movements are used to extract basic information about the patient, such as range of

WO 2005/074373 PCT/IL2005/000142

motion and freedom of motion. Optionally, device 100 first applies or suggests a series of
exercises meant to warm up muscles and joints, before taking measurements.
Attachment to body

In Fig. 1, tip 108 is held in a patient's hand. To attach to other parts of the body, other
5 means may be used. In one example, a strap or elastic ring is provided at end 108 instead of a
ball-like handle. In another example, a rod-like handle is provided instead of a ball-like handle.

Fig. 6 shows an elbow holder 600, in accordance with an exemplary embodiment of the
invention. Such an elbow holder can be used, for example, when the motion required is of the
shoulder, so an elbow 616 is what moves along a trajectory. A base 602 is adapted for
10 attachment at tip 108. A hinge 604 allows relative motion between a first part 606 and a
second part 608 on which an arm 614 rests. Optional straps 610 and 612 optionally attach arm
614 more firmly to holder 610. Optionally, joint 604 has a varying resistance, for example
settable by the patient and/or by device 100. Alternatively or additionally, joint 604 includes an
actuator for applying force to close or open elbow 616. Alternatively or additionally, joint 604
15 includes an angle sensor. Optionally, holder 600 can vibrate the elbow, for example as a
therapeutic effect or to help prevent freezing of the joint. Such vibration may be applied to
other joints and body parts as well, for example, using suitable attachments.

In an exemplary embodiment of the invention, holder 600 functions as a spastic harness
in one example, joint 604 is locked (or is not a joint) and arm 614 is forced open and held by
20 straps 610 and 612.

In an exemplary embodiment of the invention, parts 608 and 606 are raised so that joint
604 has a center of rotation which is substantially the same as elbow 616, in one or more
planes.

In other embodiments of the invention, attachment to other points on the body is
25 provided. In particular, it is noted that in some embodiments of the invention, what is
constrained is a joint, while in other, what is constrained is a bone or a certain location on a
bone. As noted above, various types of constraints can be provided, for example, constraints
on angular and/or spatial dimensions. Additional attachments are described with reference to
Fig. 16 below.

30 In an exemplary embodiment of the invention, the attachment includes a coded circuit

or other means so that when attached to arm 102, device 100 is aware of the type of
attachment.

In some embodiments, the attachment is fitted with a quick connecting elements made

WO 2005/074373 PCT/IL2005/000142

out of two mechanical quick connect parts (e.g., spring loaded pin and slot arrangement) and
an electrical quick connect (e.g., spring loaded small needle contacts), this allows a fast change
over from exercise to exercise or from patient to patient. In an exemplary embodiment of the
invention, each attachment includes a chip and receives power form the connector and sends
5 data (if any) on a bus, for example a packet-type bus. Alternatively, the electrical connector is
used to directly interface measurement means (e.g., a potentiometer) of the attachment, to
device 100.
Instructing of user

Device 1 00 can provide instructions to a user in many modes, including, one or more
10 of (for various embodiments of the invention):

a) recorded speech.

b) computer animation display.

c) instruction videos.

d) motion of device 100, while patient is not attached.

15 e) motion of device 1 00 while patient is attached, possibly at a slower speed and with

commentary.

f) motion of device 100, with a dummy attached.

g) using musical notes, for example as cues or to set a tempo of motion.

h) motion of a second device 1 00, for example as a demonstration or in sequence with
20 the patient's own motion.

Training, Teaching and Quality of Motion (QoM)

While one part of a rehabilitation plan is often exercising a body part to maintaining or
increase strength or range of motion, in an exemplary embodiment of the invention,
rehabilitation includes teaching a patient quality aspects of motions and/or what motions are
25 correct.

In an exemplary embodiment of the invention, one or more of the following qualities of
a motion are of interest:

a) degree of utilization of available joints and/or joint range of motion;

b) usage of muscles where they can apply sufficient force;

30 c) motion where joints and/or muscles can achieve a better accuracy of control;

d) motion which does not approach thresholds of ability;

e) motion which does not approach danger areas (for example for a patient with
unstable joints);

WO 2005/074373 PCT/IL2005/000142

f) smoothness in motion and/or rotation;

g) distance traveled;

h) maximum force required;

i) spatial and/or energy efficiency of motion, e.g., extra motions; and/or
5 j) motion with minimum jerk

In an exemplary embodiment of the invention, quality of motion is judged using a
power law, which characterizes motions by healthy individuals. Paretic individuals are
optionally characterized as to how closely they reach this law and for which joints and/or
motion types it is reached.

10 Optionally, 'Healthy movement' is described by basic kinematic characteristics that

define quality of motion. For the arm, one such characteristic is a smooth transition of the hand
from one point to another following roughly the shortest path between the two points. A
second characteristic is that the velocity of the hand is constrained by the curvature of the path
(Viviani P, and Terzuolo C. Trajectory determines movement dynamics. J Neurosci 7, 1982:

15 431-437, the disclosure of which is incorporated herein by reference). The larger the curvature
of the path, the slower the movement of the hand is, at a constant ratio of 2/3. These kinematic
descriptions are defined mathematically, and thus, they can be used for an objective
quantification of the quality of movement.

A "Minimum Jerk" can explain the smooth and shortest movement characteristics

20 often observed in healthy people, while the "Two-thirds Power law" has been developed to
validate the relation between path curvature and hand speed. More recently, both rules have
been unified (Viviani P, and Flash F. Minimum-jerk, two-thirds power law, and isochrony:
converging approaches to movement planning. J Exp Psychol: Hum Percept Perform 17: 32-
53, 1995, the disclosure of which is incorporated herein by reference) and mathematically

25 defined as two aspects of the same intention (Richardson MJE, and Flash T. Comparing
smooth arm movements with the Two-Thirds Power Law and the related segmented-control
hypothesis. J Neurosci 22: 8201-821 1, 2002, the disclosure of which is incorporated herein by
reference). These two rules combined in one single description can be adopted for testing
quality of movement before, during and/or after treatment with device 100. Optionally, power

30 law fitting is determined by providing the patient with a range of motions, at different speeds
and extracting power-law information from the results. The law may be applied to other joints
and limbs, such as lower limbs.

Another law which may be applied relates to the relative motion of each joint in a

WO 2005/074373 PCT/IL2005/000142

coordinated motion. In healthy persons such motion takes into account the relative distances of
the various joints from the target of motion and the different accuracies of such joints. Another
law which may be applied is Fits law which relates a size of target to a time to hit the target.

These qualities may be general for a motion or particular for a patient with certain
5 abilities and lacks.

In an exemplary embodiment of the invention, such qualities of a motion are taught to a
patient by example, for example, leading an arm through correct and incorrect motions. Such
motions may be entered for example by the therapist or by the patient or be pre-programmed.
Alternatively or additionally, a patient motion is recorded and corrected and then the patient is
10 paced through the incorrect and the corrected motions. In a pre-defined motion, the motion
may be calibrated for the particular user, for example for the user's size.

Optionally, a threshold of correctness is defined, for a patient to attempt to keep all his
motions as being of a quality (in one or more parameters) above the threshold.

Alternatively or additionally, such qualities are taught by a commenting in real-time or
1 5 off-line on a patient's motions.

Thus, in some embodiments of the invention, a substantial part of rehabilitation
comprises exercising a patient in motions which are correct or teaching the patient how to
know if a certain motion he has performed is of a higher or of a lower quality.

Other types of training are not related to motion correctness. For example, a patient
20 may be trained to not ignore a damaged limb. In a related aspect, however, a patient may be
trained to use a damaged joint as part of "correct" motion, so as not to reduce a range of
motion of the joint.

In one example, the relative motion expected between an elbow and a wrist is known
(e.g., or is inputted by a therapist, such as by example) for certain motions, such as moving
25 objects on a table surface. If a patient deviates by a certain amount (e.g., defined by the
therapist) feedback is provided.
Paired Motion

In an exemplary embodiment of the invention, motion with a good arm limb is used to
train a bad limb. For example, a good arm can be used to trace a circle and then the bad arm is
30 trained to trace the circle. One advantage of such training is the intimate feedback that a patient
receives by better understanding exactly which joints and muscles are used for each motion. In
an alternative application, the "good" motion is provided by a therapist or other caregiver.

In a single arm device 100, the following process may be used:

WO 2005/074373 PCT/IL2005/000142

a) Device 1 00 optionally illustrates a correct motion, in actuality or on a display.

b) A motion is executed with a "good" limb. Optionally, the motion is corrected, using
methods as described above for editing.

c) The motion is repeated with a "bad" limb, for example using passive motion, free
5 motion or a force field. Optionally, the "good" motion is corrected before being applied to the

bad limb, for example, an expected speed reduced, a range of motion reduced or a force
reduced.

d) Feedback is provided to the patient during and/or after the motion (e.g., as a
display).

10 e) The motion is optionally repeated.

Fig. 7 and Fig. 8 shows two handle devices 700 and 800 respectively, in which two
arms can be moved simultaneously, with optional coupling. In an exemplary embodiment of
the invention, this is used to have one arm passively move the other arm, for example so the
patient can sense with the good arm what a bad arm is doing, or vice versa. Alternatively or

15 additionally, one handle is moved by the device, so the patient can see what is expected of
him. Optionally, two arm devices are used for children, for example as a game between paretic
children and healthy children or grownups.

In device 700, two separate rehabilitation devices 702 and 704 are optionally attached
by a base 706 and coupled by computer, electrically and/or mechanically, so that an arm 708 of

20 one mimics the motion of an arm 710 of the other. The arm moving mechanism is optionally a
ball based mechanism as described below.

In device 800, a single joint links two arms 808 and 810. As a result, the motions are
reversed. Optionally, arms 808 and 810 are extendible (as described below, for example) and
are linked together so that they both lengthen and shorten together, for example, the two arms

25 including extensions that are engaged on opposite sides of a gear with a fixed center of rotation
(e.g., a rack and pinion mechanism).

In an exemplary embodiment of the invention, mirrored motion is provided using other
devices. For example, in an application using standard devices, mirrored motion is provided by
a user holding one mouse in either hand (or in a same hand sequentially) and applying the

30 above transfer of motion form one hand to the other. In another embodiment, one or two force-
feedback joysticks are used. It should be noted that for this and other embodiments a plurality
of devices may be used. In particular, for specific applications, relatively simple and/or
standard hardware can be used, for example force feedback joysticks or haptic displays.

WO 2005/074373 PCT/IL2005/000142

Complex Motion

Fig. 9A illustrates a rehabilitation device 900 comprising two sections, a first section
902 associated with motion of a wrist and a second section 904 associated with motion of an
elbow. Sections 902 and 904 can be ball-based devices as described below. A rigid and
5 optionally adjustable connection 910 fixes the relative position of sections 902 and 904. A
connection 912 optionally interconnects a wrist holder 906 and an elbow holder 908. Device
900 is used to exemplify control of multiple points on a limb (e.g., arm or leg) during
rehabilitation.

In use, each of holders 908 and 906 can be controlled in three spatial dimensions and

10 optionally in angular dimensions as well, thus allowing more complex motions to be tested,
trained and/or provided. Optionally, the possibility of restricting certain motions is useful from
a safety point of view, for example, preventing certain rotations of the joints. Optionally, a
point is controlled in 3, 4, 5, or 6 degrees of freedom of motion. Optionally, the control in
some of the degrees of freedom is different than in others. For example, motion in one axis

15 may have resistance associated therewith, while an angular motion may be assisted motion
with device 900 supplying some of the force.

It should be noted that in device 900, trajectories may be defined as relative trajectories
in which the actual position of the device 900 is less important than the relative positions and
movement in space of holders 906 and 908.

20 Fig. 9B illustrates a rehabilitation device 920, including a single section 928 with an

arm 932, on which is mounted an arm holder 930. Holder 930 restrains both an elbow using an
elbow holder 924 and a wrist, using a wrist holder 922. An optional rotation mechanism 926 is
shown for rotating holder 930 perpendicular to arm 932 while an optional rotation mechanism
940 rotates holder 930 around arm 932. Alternatively or additionally, a similar mechanism (not

25 shown) is optionally provided for rotating holder 930 around its axis.

As will be described below, another type of complex motion which can be supported
by a rehabilitation device in accordance with an exemplary embodiment of the invention
requires synchronized motion of several body parts, for example, an arm and a leg.
Ball-Based Device

30 As noted above, designs other than an articulated arm may be used for device 100. In

particular, in an exemplary embodiment of the invention, the device is based on a universal
joint, from which extends a rigid arm, which is optionally changeable in length.

In an exemplary embodiment of the invention, the universal joint is implemented as a

WO 2005/074373 PCT/IL2005/000142

ball in socket joint. Fig. 10 shows an exemplary rehabilitation device 1000, using a ball-in-
socket joint. This reference number is used in the general sense for several ball-based devices
as described herein, for conciseness.

Device 1000 comprises a base 1004, for example a table containing a plate 1016, with
5 an aperture 1017 defined therein and enclosing a ball 1010. Ball 1010 optionally rests on a
plurality of rollers 1012. In an alternative embodiment shown in Fig. 11, rollers 1012 are
replaced by a bottom plate 1015 with an aperture 1013 defined therein which supports ball
1010.

An arm 1002 extends from ball 1010 and is optionally balanced by a counter- weight
10 1018 attached by a rod 1022 to an opposite side of ball 1010. Rod 1022 optionally passes
through a slot in an optional guide plate 1020, described in greater detail below.

In use, ball 1010 turns and/or rotates, allowing a tip 1008 of arm 1002 to define various
trajectories in space. Optionally, arm 1002 is extendible, so that the trajectories fill a volume of
space. Optionally, arm 1002 includes a motor or brake 1024 (e.g., an oil brake), to actively
1 5 move or passively resist such extension.

In an exemplary embodiment of the invention, a brake 1014 is provided for ball 1010.
One potential benefit of using a relatively large ball 1010 is that torque at the surface of the
ball, for example as required for braking or moving arm 1002 is generally smaller than
required for smaller joints, possibly allowing the use of smaller or cheaper motors or other
20 mechanical elements. Alternatively or additionally, positional control of such motors and/or
sensitivity of position sensors can be smaller, while still allowing for sufficiently precise
control and feedback.

Device 1000 can be provided in various configurations. In a simplest configuration, the
device is completely passive and a user can merely set plate settings (described below) and

25 resistance settings on the brakes. In a more advanced configuration, resistance can be varied in
real-time by a computer control. In another advanced configuration, sensing of ball and/or arm
position is provided (e.g., using sensors, not shown). In another advanced configuration,
directional resistance can be varied (e.g., using a directional brake, not shown). In another
advanced configuration, motive force, optionally directional can be set or varied, for example

30 using a plate and/or using multiple directional motors (which can also be used to provide
resistance).

In an exemplary embodiment of the invention, multiple motors are used to control
motion and/or force of arm 1002. The motors optionally include optical position encoders, to

WO 2005/074373 PCT/IL2005/000142

determine an arm position. Alternatively or additionally, stepper motors or servo motors are
used. Alternatively or additionally, a separate sensor, for example, one which reads optical
markings off of ball 1010, is used. In an exemplary embodiment of the invention, rollers 1012
are replaced by motors which rotate wheels. If one wheel is in a direction (relative to the
5 surface of ball 1010) perpendicular to another such wheel, selective motion in one or both
directions can be achieved (e.g., if motion perpendicular to the wheel is low-friction slipping
motion). Alternatively, only one roller is replaced by a motor with a turning wheel, wherein the
wheel is turned to a direction of motion desired and then rotated to achieve the motion.
Directional resistance is optionally achieved using the motor. Alternatively, such resistance is

10 achieved by a combination of the motor applying force or resistance and a general resistance
applied by brake 1014. Optionally, one or more strain sensors are provided or integrated in the
motor(s), to assess a direction of force being applied to arm 1002. Then, the motors can
respond with a counter-force, or an assisting force or a diverting force (e.g., with a component
perpendicular to the applied force), as required.

15 In an exemplary embodiment of the invention, brake 1014 is operated by raising and

lowering the brake towards the equator of ball 1010, when the brake has an inner diameter of
less than that of the ball. Alternatively, the brake is inflated and deflated as needed.
Alternatively or additionally, a circumference of the brake is modified, for example, by it being
formed of shape memory alloys which are heated to cause momentary expansion and/or

20 shrinkage of the brake. Alternatively or additionally, a perpendicular brake is used which is
pressed onto the surface of ball 1010 and towards the center thereof.

Alternatively or additionally to a uni-directional brake, directional brakes may be used,
for example, rubber blades-like pads which resist motion of the ball along the blade by bend
with relatively low friction to allow motion perpendicular to the blade.

25 It should be noted that when arm 1002 is extendible, forces applied to point 1008

generally include also a component along the axis of arm 1002, to which brake or motor 1024
may respond and which is optionally taken into account in the response of ball 1010.
Balance

Fig. 11 shows a balancing of device 1000, in accordance with an exemplary
30 embodiment of the invention. As noted above, Fig. 11 shows a variant of device 1000, in
which ball 1010 is supported by plate 1015. Weight 1018 is optionally designed to exactly
cancel the moment of arm 1002. Alternatively, it may be designed, or modified (e.g., by
changing its distance from ball 1010 or by adding or removing a modular weight), to provide a

WO 2005/074373 PCT/IL2005/000142

force which return arm 1002 to a resting position or a force which tends to move it away from

such a resting position. In some cases, balancing may be adjusted to correct for a weight of an

attachment, or of the patient's limb.

Optionally, when arm 1002 is extendible, the extending part includes a moving
5 counter- weight that extends away from the center of ball 1010 in a manner which maintains

the center of gravity of ball 1010. This motion may be solely inside of ball 1010.

Alternatively or additionally, balancing of ball 1010 is provided by active balancing by

the motors and/or brakes. Such active balancing may also be used to effectively reduce or

cancel out the moment of inertia of ball 1010 and arm 1002.
10 When an attachment is added to tip 1008, this may change the balancing. Optionally, a

suitable weight is provided with each such adjustment, for adding to balancing weight 1018.

Alternatively, handle 1 008 includes one or more contacts and/or circuitry which match one or

more contacts or circuitry in a mating part of the attachment. This allows device 1000 to detect

which attachment is being added and suitably move weight 1018 to compensate. Suitable
15 tables are optionally downloaded from a remote site. Alternatively, the attachment includes a

peg of suitable length which pushes into tip 1008 and thereby moves an arm balancing weight

inside of ball 1010. Movement of weight 1018 is optionally by a motor (not shown) and may

be, for example, along a rod 1022 and/or away from a line connecting rod 1022 and arm 1002.

Alternatively or additionally, device 1000 self calibrates by detecting an applied torque
20 moment and moving weight 1018 (or other weights) to compensate.

Optionally, the balancing is designed relative to an expected weight or force applied by

a person during an activity.

Fig. 1 1 also shows rod 1022 being constrained to travel in a straight line by a slot 1030

in plate 1020.
25 Guide Plate

While, in general, computer controlled directional motors and brakes can achieve any
desired motion, in some embodiments of the invention, a possibly more limited motion is
supported by the use of plate 1020 and its associated slots 1030. A potential advantage of
using guide plates is that movement perpendicular to the slot is not generally possibly, and this
30 does not required suitable circuitry.

Fig. 12 illustrates a drive system for a plate-based rehabilitation device, in accordance
with an exemplary embodiment of the invention. A first, optional, motor 1 046 is attached to a
gear 1048 which rotates plate 1020 to allow motion of rod 1022 in other than a straight line. A

WO 2005/074373 PCT/IL2005/000142

second, optional motor 1040 is attached to a threaded rod 1042 on which a rod coupler 1044
travels. As coupler 1044 travels, it moves (or resists) rod 1022 along slot 1030. Other
mechanisms can be used as well.

As noted in Figs. 3A and 3B, it is sometimes desirable to provide varying, rather than
5 absolute resistance to motion perpendicular to slot 1030. Fig. 13A illustrates an exemplary
coupling device 1300 for replacing coupler 1044, and which has this property. Coupling device
1300 includes a body 1314 having an inner threaded section 1302 for mounting on threaded
rod 1042. Body 1314 further comprises an apertured element 1306 having an aperture 1304
which engages rod 1022. One or more spring elements 1308 couple element 1304 to body
10 1314. Optionally, the tension in spring element 1308 can be adjusted, for example by a screw
1310. Optionally, a linear displacement sensor 1312 is provided to measure the error in the
position of rod 1022. Elements 1308 can be provided, for example, in the direction of slot
1030 and/or perpendicular to it. Other exemplary force control mechanisms are described with
reference to Figs. 22-26.

15 Fig. 13B shows an elastic guide 1340, formed of two halves 1342 and 1344 coupled by

one or more springs 1352 and 1354. Thus, a slot 1346 formed between two edges 1348 and
1350 of the halves has some elastic give. Alternatively or additionally, edges 1348 and 1350
are made at least partially elastic, for example, of rubber.

Figs. 14A illustrates a variant device, in which two guide plates are used in tandem, an

20 upper guide plate 1020 and a lower guide plate 1402. Separate motors are optionally provided
for rotating each guide plate.

Fig. 14B shows a guide plate with several slots. The solid areas are provided to prevent
the cut-outs from falling out. Other methods, for example, out-of-plane bridges, may be used
instead.

25 Fig. 14C shows a guide plate with an "X" shaped slot. Other shapes can be provided as

well, for example a circle with a cross inside, or curved slots.

In an exemplary embodiment of the invention, programming device 1000 includes

replacing slots and/or setting resistance. Optionally, when a slot in inserted, it is recognized by

device 1 000, for example, using a contact based detection scheme as described above or using
30 a wireless or RF communication, for example, by embedding a smart card circuitry in the

plate.

Accessories & Wrist Attachment

Fig. 1 5 A shows a wrist attachment 1 500, which provides control and/or feedback for

WO 2005/074373 PCT/IL2005/000142

one or more degrees of motion of a hand, in accordance with an exemplary embodiment of the
invention.

A forearm is supposed to rest on a rest 1510, while a grip 1502 is grasped by the hand.
Grip 1502 is gimbaled in one or more axes relative to rest 1510. In the example shown, handle
5 1502 is mounted on a base 1503 which includes a rod 1504. A joint section 1506 can
optionally rotate around the axis of rod 1504 and/or travel along it. In addition, an optional rod
1508 interconnects rest 1510 and joint section 1506 and allow rotation around rod 1508. In
addition, an optional rod 1512 meets joint section 1506 at a direction perpendicular to the
other two rods and allows rotation around that third axis.

10 Optionally, wrist attachment 1500 is attached to tip 1508 at rest 1510 or at a base

section 1514 attached to rod 1508.

Optionally, one or more of the relative motions described is supported by one or more
motors and/or controllable brakes.

In some wrist attachments (or for other attachment devices), one or more springs the

15 handle to the rehabilitation device so as to provide the varying resistance shown in Figs. 3 A
and 3B, in one or more dimensions.

Fig. 15B shows a wrist attachment 1520, according to an exemplary embodiment of the
invention and generally following the form of device 1500. A handle 1522 is griped by a
patient, while the patient's arm rests on an arm rest 1524. Optionally, one or more straps are

20 provided (not shown) which can attach via one or more strap slots 1526. A base 1542 affords
attachment via a connector 1528 to an arm 102 (not shown, but exemplified in Fig. 15C). In an
exemplary embodiment of the invention, a universal connector is used which is suitable for
multiple attachments as described herein, for example. In an exemplary embodiment of the
invention, the connector provides one ore more of mechanical fixation, power (e.g., electrical

25 power) and data transfer. Optionally, the connector also provides identifying information about
the attachment to device 100.

In the embodiments shown, three wrist rotations are supported, by mechanical joints
1530, 1532 and 1534. Optionally, the resistance at one or more of the joints is adjustable. In
the embodiment shown, the adjustment is manual, for example using one or more of knobs

30 1536, 1538 and 1540. Alternatively an internal adjustment, for example, using a small electric
motor, is provided. The resistance may be, for example, of a friction type or of a resilient (e.g.,
spring) type. Optionally, rotation sensors are provided for each joint, for example
potentiometers.

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Optionally, handle 1 522 is replaceable, for example, using a pull-pin 1 544 to selectably
unlock handle 1 522 for removal.

Fig. 15C shows a different version, of a wrist attachment 1550, similar to wrist
attachment 1520 (e.g., a knob 1552 is at a different place from knob 1538) and shown from an
5 opposite side. Also shown is the mounting of the wrist attachment on an arm 102. In an
exemplary embodiment of the invention, the mounting comprises a ball and socket joint,
optionally with friction resistance. Optionally, the socket joint is designed to disconnect if it
experiences torque above a certain level, for example as a safety feature. Optionally, this safety
level is settable. In an exemplary embodiment of the invention, the joint comprises a ball held
10 between two plates, with the plates interconnected by springs with a settable resistance. A wire
interconnecting the plates is optionally provided and may generate a signal is torn (e.g., springs
over strained). Optionally, a safety tether is provided to keep the parts of the joint together.

Another difference is that instead of a single arm rest 1524, two arm rests, 1558 and
1556 are shown. Optionally, straps are provided only for the far arm rest (1558). Optional
15 padding 1560 is also shown.

Fig. 15D shows a non-vertical handle attachment 1560. While a 90 degree angle is
shown in a bend 1562, other angles, for example 45 degrees may be provided. Optionally, the
angle allows better control over which muscles will act and/or may make some motions easier.
Optionally, bend 1562 is adjustable, for example to preset angles, such as 0, 45 and 90 degrees.
20 An optional universal attachment 1564 is shown.

Fig. 15E shows a grip 1570 in which optional finger indentations 1572 are shown. An
optional button 1574 for input form the patient is shown. Additional buttons may be provided
and buttons may be provided in other embodiments as well.

Optionally, a body 1576 of handle 1570 is squeezable (as it may be in other
25 embodiments as well). One type of squeezable body includes a gas-filled bladder. Optionally,
the compression of the gas can be varied to change the resistive force. In an alternative
embodiment, body 1576 is formed of two panels separated by one or more springs.

An optional universal attachment 1578 is shown.

Fig. 15F shows a two handle embodiment 1580 including two handles 1582 and 1586,
30 which are optionally changeable via pins 1584 and 1588. This embodiment may be useful, for
example, when it is desired for one hand to assist the other hand in a motion. The two handles
actually used need not be identical.

An optional universal connector 1590 is shown.

WO 2005/074373 PCT/IL2005/000142

Other attachments may be used as well. In one example, a cup like attachment is used.
A patient can hold the cup as a glass or hold it using a pinching action by its handle. Various
sensors to measure pinching force and or grip force (as may be applied to the glass) may be
provided. Alternatively, attachments known in the art can be used, optionally being modified
5 to include a universal connector and/or suitable sensors. Optionally, an attachment with a strap
to hold the hand is provided.

Optionally, the attachment used provides a sensation to the patient, for example,
vibration, pricking, pinching or a surface texture. Electrical power may be provided to the
attachment, as well as data, to generate and control such sensation. Surface texture may be
10 varied, for example, by providing a smooth layer with an underlay that is bumpy. Extending
the bumps or the bumpy layer, will vary the surface texture.

While the attachments are described for the arm, it should be appreciated that such
attachments can be provided to other limbs and to the head and neck. In one example, a pedal
is provided as an attachment for a foot. The various rotations of the wrist attachments may also
15 be provided for the foot. Similarly, a head and neck attachment may be designed to hold the
support various rotations and/or movements of the chin relative to the neck.

Another type of attachment is not mounted directly on arm 102, patches 504 for
example (Fig. 5).
Elbow Support

20 Figs. 16A-16D illustrate various methods of elbow support in accordance with

exemplary embodiments of the invention. As noted above, for some rehabilitation methods it
is useful to provide support for and/or prevent motion of the elbow (or other body parts). In an
exemplary embodiment of the invention, device 100 supports the weight of the limb so that a
patient can focus on moving the limb and not on holding it in space. Conversely, device 100

25 may be set to prevent the patient from leaning on the device, for example, with device 100
providing exactly the force expected to be applied by the limb (optionally with some leeway).
Optionally, the degree of force changes along the trajectory, for example, as the limb extends.

Fig. 16A shows an elbow support 1604 attached by wires to a frame 1602, fixed to the
rehabilitation device. Optionally, frame 1602 is collapsible. Optionally, frame 1602 is designed

30 to allow entry of a wheel chair so that a patient on a wheelchair is not required to leave the
chair for rehabilitation. One or more foot pedals 1 609 are provided for exercising and/or other
rehabilitation activities of the legs. Optionally, the pedals are used to support coordinated
exercises between arms and legs. Pedals that move in more than one degree of freedom may be

WO 2005/074373 PCT/IL2005/000142

provided, as well as various sensors as described herein. A perpendicular motion mechanism
1 606 is shown, which may provide room for the knees of a patient sitting in a wheelchair.

In a simplest embodiment, wires 1605 are set (e.g., their length) to a desired elbow
location. Optionally, three wires are used so that elbow support 1604 can be fixed in space.
5 Optionally, more wires, for example, four wires are provided, so that even when not occupied,
support 1604 does not move. While wires may be used to set an elbow support, such wires
may also be used to support other body parts. Optionally, multiple sets of wires are provided,
for supporting multiple body parts. Optionally, a wire based system is used instead of an arm
102 or 1002 to control the position of a tip (or attachment) or point on a body.

10 In an exemplary embodiment of the invention, a wire system is used for measurement

of a position in space. In one example, a wire 1605 recoils and is attached to a measurement
device such as an encoder. Interpolation can be used to provide XYZ coordinates of support
1604. In another example, described above as well, wires are used to measure a relative
position of a chair and a rehabilitation device (e.g., frame 1602).

15 Optionally, a wire mechanism is attached between two limbs and used to determine

their relative distance. Multiple wires may be used to determine more than just a distance
value.

Optionally, a wire system is used for measuring additional parameters, for example,
force applied to a limb (optionally including direction) and speed of motion. It should be noted
20 that a combined system including (for a same point or tip 1 08) both robotic elements and wire
elements, may be provided.

In an exemplary embodiment of the invention, a wire system is controlled, for example
using a motor, to maintain a certain tension. Optionally, this is used to allow floating support
of a limb. Optionally, motors are used for controlling or assisting motion, for example with a
25 motor being used to shorten a wire or allow a wire to play out at a certain speed or if a certain
force is sensed.

Optionally, a wire 1605 provides compliance against tension, for example, by
providing a spring attached to a wire 1605 (e.g., at a point 1608, where a motor may be
provided as well). Optionally, the tension in the spring may be varied, for example, using an
30 electric motor. Optionally, the spring is used to provide cushioning in general.

Fig. 16B shows elbow support 1604 supported by an arm 1610 which extends from the
rehabilitation device. Optionally, arm 1610 includes a linear extension measurement element
and two rotary measurement elements, to indicate the position of support 1604. Other

WO 2005/074373 PCT/IL2005/000142

embodiments described herein may also include such sensors so device 100 can calculate the
position. Also, as noted, force sensors may be provided, to assist in analyzing the forces
applied by the patient to support 1604.

Fig. 16C shows elbow support 1604 supported by a jointed arm 1620 which extends
5 from the rehabilitation device.

Fig. 16D shows elbow support 1604 supported by a member 1630 which extends out of
(and/or is mounted on) arm 1002.

Optionally, the extending arms and members are configurable. Alternatively or
additionally, the arms include motors and/or variable resistance elements. Alternatively or
10 additionally, the arms and links include position, orientation, displacement and/or force
sensors. In an exemplary embodiment of the invention, the actual position of various parts of
the arm may be determined based on the fact that one or more parts of the arm are fixed and
the length is known. If any joints are provided, the angle of the joint may be measured.

An additional elbow support example is shown in Fig. 1 9, below, in a docking station.
15 Varying Orientation

In some embodiments of the invention it is desirable that arm 102 have a center resting
position which is not vertical. Fig. 17A shows a rehabilitation device 1700, including a joint
1702 between a base 1704 thereof and a movement mechanism 1706 thereof, which can
assume multiple orientations.
20 Alternatively, one of the above described rehabilitation devices may be mounted on a

surface other than the floor or on legs with uneven lengths. Optionally, when device 1000 is
mounted on a wall or upside down, rollers such as rollers 1012 are provided above ball 1010
as well, so that they can support ball 1010, when device 1000 is on its side or upside down.
Mounting is achieved, for example, by screws or using an adhesive.
25 One potential advantage of a varying orientation rehabilitation device is the ability to

rehabilitate a patient in varying positions. For example, some exercises, for example those
including reaching and balance may be usefully practiced while standing up. Some exercises,
must be practiced while lying down, as the patient is bed-ridden. Some exercises may be
practiced sitting and others while kneeling.
30 Another potential advantage is that a same system may be used to rehabilitate different

body parts with a same device.

Another potential advantage of a varying orientation rehabilitation device is that many
arm motion mechanisms are limited in their range of motion, coupling between axes and/or

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other mechanical considerations. Varying the orientation of the device allows the motion
mechanism to be placed at a more optimal position. It should be noted that in some varying
orientation devices, the controlled tip 108 of the device can stay in a same location even
though the motion mechanism has moved. This allows, for example, that a patient remain in a
5 wheelchair during a change in exercise.

While a manual change in orientation is shown, optionally one or more motors are used
to effect the change in orientation. One or more angle sensors may be provided to detect the
actual rotation of joint 1702 (in one or two directions).

Fig. 17B and Fig. 17C show an alternative varying orientation rehabilitation device

10 1710, in two orientations. In Fig. 17B, an angled orientation is shown, a support slab 1724
positions a motion mechanism 1720 and an arm 1722 relative to a base 1712. Optionally, one
or more extendible legs 1714 are provided for stability. Optionally, a wheelchair guide 1716,
optionally extendible, is provided. Optionally, guide 1716 is slotted to allow a wheel to enter
therein. Optionally, chucks are added on either side of the wheel to lock the wheel in place.

15 Not shown is an optional bracket based locking mechanism in which one or more pins or
brackets engages the wheel from one or both sides thereof, for example along the wheel axis.
Such a mechanism may be electrically actuated, for example, by the patient himself. This
wheelchair locking mechanism may be used in other embodiments of the invention as well.

In an exemplary embodiment of the invention, slab 1 724 can be positioned at various

20 angles. Fig. 17B shows an angle of about 45 degrees. Fig. 17C shows a 90 degree angle. Also
shown in Fig. 17C, is a second support slab 1726 attached by a lockable hinge 1728 to support
slab 1724. In Fig. 17B slab 1726 is flat against base 1712. Additional possible modes are a 0
degree angle, in which slabs 1724 and 1726 lay flat in a recess 1734 of base 1712. A hinge
1730 is used to rotate motion mechanism 1720 so that it faces upwards. Optionally, motion

25 mechanism 1720 is coupled to hinge 1730 via a rotatable base 1721. Another exemplary
position is with slab 1724 lying flat in a recess 1732, so that rotatable base 1721 also lies in
recess 1732. This is a transport mode, in which arm 1722 may be detached and the whole of
device 1710 may fit, for example, in a trunk of a car. Slab 1726 is optionally attached to base
1712, by another lockable hinge (not shown).

30 Fig. 17D shows an alternative rehabilitation device 1740 with an adjustable position of

a motion mechanism 1748 thereof. In this embodiment, a rail 1744 extends from a base 1742
and motion mechanism 1748 is coupled to a traveler 1746 which rides on rail 1744.
Optionally, motion mechanism 1748 is attached by a hinge to traveler 1746, to better utilize

WO 2005/074373 PCT/IL2005/000142

the range of motion of mechanism 1748 (e.g., allowing an arm 1750 of device 1740 to be
centered in a center of a motion space using traveler 1746, rather than using mechanism 1748).

Rail 1744 optionally folds for travel. Rail 1744 optionally includes an in-built data and
power bus for transferring at least power to mechanism 1748. Alternatively, a flexible cable
5 (not shown) is used. Base 1742 (as other bases shown herein) may optionally include wheels.
Multi-Limb Devices

In an exemplary embodiment of the invention, multiple limbs can be trained together,
for example, for rehabilitating synchronized motion. In an exemplary embodiment of the
invention, multiple modules such as used in device 1 000 are attached in various configurations
10 to achieve this effect. The attachment can be, for example, structural (e.g., preventing
undesired relative motion, but possibly adjustable), mechanical, for example transmitting
motion from one module to another, and/or controlled, for example, modifying the interaction
at one module in response or in synchrony with interaction at another module.

Fig. 1 8 shows a rehabilitation device 1 800 for an arm and a leg, in accordance with an
15 exemplary embodiment of the invention. Device 1800 includes a first section 1804 for
exercising an arm, for example using a mechanism of device 1000, and a second section 1802
for exercising a leg, for example also using the mechanism of device 1000.

One exemplary use for this type of device is to rehabilitate a stroke victim with one
side paralysis. Another exemplary use is to train synchronized motions, such as required for
20 walking.

In some cases, two sided rehabilitation is desirable. Fig. 19A shows a rehabilitation
device 1900 with four mechanism modules. A pair of modules 1902 and 1904 is used to
control the movements of a right arm and a pair of mechanism modules 1906 and 1908 is used
to control the movements of a left arm. The two pairs of modules can be synchronized and/or

25 used for teaching, for example, as described above.

Optionally, one or more modules are added for exercising each leg. In the example
shown, one or more pedals 1910, such as in Fig. 16A are provided. However, as noted above,
devices with a greater degree of freedom can be used. Optionally, gait training mechanisms,
for example as described in US provisional application no. 60/633,428 filed on December 7,

30 2004, also being filed as PCT application on same date as the present application and by the
same applicant, entitled "Gait Rehabilitation Methods and Apparatuses" and having attorney
docket number 414/04391, the disclosures of which are incorporated herein by reference, are
used. Optionally, such mechanism includes a support which attaches to an ankle and can rotate

WO 2005/074373 PCT/IL2005/000142

and/or translate the ankle (e.g., foot) in various (e.g., 2,3,4, or more) directions so as to
rehabilitate walking. Optionally, one or more mechanism modules are provided for training hip
motion, even while sitting. Optionally, a tread-mill or training bicycle is provided for the
patient to walk on while exercising his upper body. Motion of the treadmill is optionally
5 synchronized to rehabilitation exercises and actual performance by the patient. Optionally, gait
training includes individual training of different parts of the body and then training them
together for a complete (or partial) gait.

Optionally, device 1900 is used with a wheelchair and not a standard chair.
Docking system

10 Fig. 19B shows a docking station 1920 and Fig. 19C shows docking station 1920

occupied by a wheelchair 1922. By docking station is meant a structure to which a patient can
be brought and locked into place and then rehabilitated. From a functional point of view it is
generally desirable that only a minimum of manipulation of the patient be required for
rehabilitation work to start. Thus, for example, the patient can stay in the wheelchair and

15 optionally instead of adjusting the patient's position (e.g., initially and when exercises change)
the rehabilitation device moves, optionally autonomously, to ensure correct relative
positioning.

In the embodiment shown, two varying orientation modules 1924 and 1926 are
provided on a track 1928. Optionally, the modules are moved by hand. Alternatively, motors
20 (not shown) change the configuration of the modules and/or move them along track 1928.
Track 1928 optionally provides power and/or data to the modules. Also non-varying
orientation modules or other rehabilitation devices may be attached.

An optional wheel-chair holding mechanism 1932 is shown positioned on a track 1930.
Optionally, the position is changed manually. Alternatively, the position is changed using a
25 motor (not shown). Similarly, the wheelchair-engaging mechanism can be manual or
motorized.

A set of foot pedals 1934 is shown, but it could be replaced by other foot-training
devices.

An optional elbow support 1936 is shown, attached to a joint 1938. Optionally, elbow
30 support 1936 is floating with respect to the person, optionally adjusted to compensate for the
weight of the patient. Optionally, the floating is in a plane, for example in a plane parallel to
the floor. Optionally the location of the elbow is measured by the support and can be used for
various feedbacks such as measurement of quality of motion. Support 1936 is optionally on a

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telescoping and/or articulating arm, for example as described in Fig. 16.

A display 1940 is optionally provided, for example for use of a therapist and/or the
patient. An input system 1942, for example a keyboard and a joystick may be provided as well.
Optionally, the input and output devices 1 940 and 1 942 can be swiveled to different positions,
5 so that the therapist can access them while docking station 1920 is occupied.

Display 1940, input 1942 and/or joint 1938 are optionally mounted on a column,
optionally a telescoping column. Optionally, a display 1946 (audio and/or visual) dedicated to
the patient is provided.

A similar docking station may be provided for a gurney, for example with four motion
10 mechanisms, one for each limb. Alternatively, as described below, the rehabilitation device is
made portable enough so that it may be brought to a bed-ridden patient.
Mobility

A feature of some embodiments of the invention is that a rehabilitation device is
provided which is mobile. There are various levels of mobility and various embodiments of the
15 invention, as described herein can achieve these levels.

In an exemplary embodiment of the invention, mobility of a rehabilitation device is
used to move the device within a ward or between hospital wards.

Fig. 19D shows mobile rehabilitation devices 1950 positioned near a bed 1951, in
accordance with an exemplary embodiment of the invention. In this embodiment of a mobile
20 device, a motion mechanism 1952 is mounted on a rail 1958, for example a curved rail with a
base 1960. Wheels, optionally lockable and/or extending legs (not shown) may be provided on
base 1960. Rail 1958 optionally includes one or more tracks 1962 (slots shown) for adjusting
the position of mechanism 1952. Two different attachments are shown, 1954 for an arm and
1956, for a leg. Optionally, the wheels are used to move device 1950 into storage. Collapsible
25 devices were described above, for example in Fig 17B.

Fig. 19E shows an alternative mobile rehabilitation device 1964, coupled to bed 1951,
in accordance with an exemplary embodiment of the invention. One or more attachment
mechanism 1972 lock device 1964 to bed 1951. Wheels are optionally provided. Device 1952
may be used, for example for rehabilitation from above. In an exemplary embodiment of the
30 invention, device 1964 comprises a frame 1970 on a top part 1966 of which a movement
mechanism 1952 is mounted. Optionally, device 1952 can move along the frame. A ball grip
attachment 1968 is shown.

Mobility may also be useful in other settings, for example, at home or in a small clinic.

WO 2005/074373 PCT/IL2005/000142

Also, as noted above, a mobile rehabilitation device may be carried by a therapist on home-
calls.

In an exemplary embodiment of the invention, rehabilitation is performed in water (or a
steam bath), or with water supporting the patient and/or providing heat and/or massage. Fig.
5 19F exemplifies the use of mobile rehabilitation devices 1972 in a bathtub 1976, in accordance
with an exemplary embodiment of the invention. A wheeled base 1978 is shown, but other
base types, including a fixed base, may be used. In the embodiment shown, two arm
attachments 1974 with extended connections are used and the patient may be sitting or lying
down.

10 Rehabilitation may also be carried out in a swimming pool, with device 1972, for

example, being attached to a ceiling above the pool.

In an exemplary embodiment of the invention, the rehabilitation device is kept outside
the water, but attachments are made waterproof. Optionally, the device itself is made
waterproof or at least splatter-proof. Optionally, the rehabilitation device is made battery

15 operated, to prevent electric-shock hazard. Alternatively, pneumatic or hydraulic motors are
used instead of electric motors. Optionally, low- voltage (e.g., 24, 12, 5 volts or less) are used
to power the rehabilitation device. Optionally a device without motors that includes brakes, is
used

In an exemplary embodiment of the invention, the mobility of the rehabilitation device
20 is used for rehabilitation in the outdoors, for example in a person's garden (e.g., on grass) or in
nature. In one example, a rehabilitation device is used for a recreational activity such as
barbequing. The device can be used to help guide, diagnoses and train a patient in flipping
hamburgers, for example. Optionally, large wheels are provided for better traveling over soft
surfaces. In another example, the rehabilitation device is used to rehabilitate outdoor activities
25 such as golf or fishing. Optionally, special attachments are provided for such activates, to
match the range of motion of the movement mechanism used to the activity. In a fishing
example, the rehabilitation device can assist for example in holding a fishing rod, generating
range of motion in the shoulder to through a fly and in resisting the pull of a fish (which is a
varying force). Exemplary attachments are an attachment to a fishing rod and an attachment to
30 a tip of the rod (e.g., simulating a fish).

In an exemplary embodiment of the invention, a leveling mechanism is provided for
uneven surfaces. This mechanism, for example, similar to that of Fig. 17A includes an
inclination sensor which detects the level plane and adjusts the motion mechanism to be

WO 2005/074373 PCT/IL2005/000142

arranged suitably.

In an exemplary embodiment of the invention, a tip and or tilt detection mechanism is
provided. Optionally, when tipping is detected (e.g., acceleration of the base of a rehabilitation
unit), the unit generates a warning signal. Optionally, any attachments to the patient are
5 released, to prevent damage to the patient. Optionally, the base includes collapsible sections so
that if tipping is detected, the base can collapse one section thereof and cause the device to fall
away from the patient.

In an exemplary embodiment of the invention, a mobile rehabilitation system for use
out side of a sterile environment is made easier to clean and/or proof against spills, dirt and
10 some weather conditions. Optionally, the electronics and motion mechanisms are sealed.
Optionally, joints are covered with flexible rubber so that fewer bumps and cracks are present.
Optionally, a wipe-clean plastic covering is provided on the device.

In an exemplary embodiment of the invention, the rehabilitation system is mounted on
a wheelchair, for example on its side or in back, or in a car, for example, in the seat near a
1 5 driver. Optionally, the device can be fitted in the back of a van and the van is configured to be
used as a mobile rehabilitation unit, where a patient can enter (possibly in a wheel chair,
possibly using a lift) and exercise.
Modularity

In an exemplary embodiment of the invention, a rehabilitation device optionally
20 features modular design. Such modular design may manifest itself in one or more of the
following manners:

(a) The device is capable of being broken down into modules. This allows, for
example, for maintenance by replacing a defective module. Alternatively or additionally, the
mobility of a device is enhanced by the ability to take it apart into components which can be

25 quickly put together again by a layperson. In an exemplary embodiment of the invention, no
special tools are required for taking apart or for putting together the device. Optionally, a
simple screwdriver or turn wrench is used. Optionally, the device can be broken down/folded
up or put back together in less than 1 hour. Optionally, the time required is less than 30
minutes, less than 20 minutes or less than 10 minutes, 5 minutes or 2 minutes, for example.

30 (b) The device itself is a module. As can be seen for example in Fig. 19, a same motion

mechanism module can be used for multiple different rehabilitation configurations. Optionally
the unit as shown in Fig. 1 7 is used as an attachable/detachable module for the docking station
of Fig. 19B.

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(c) Modular attachments. As shown for example in Figs. 16-19, various types of
attachments can be added to a same basic device, thereby changing its usage. In a particular
example, the device is adapted for various patient sizes, for example children with Cerebral
Palsy, by replacing parts, for example an arm 102, with suitably sized parts.
5 In some embodiments of the invention the hand attachment includes mechanical and

electrical quick connections. The mechanical quick connect may include a pin that fits to a
hole with locking the electrical quick connect can includes spring loaded needles on one side
and surface pads on the others. A same set of connectors may be used for multiple
attachments.

10 (d) Modular software. Optionally, the software used by the rehabilitation device is

provided as modular software, for example, separate modules for different attachments;
modules which includes sets of exercises; separate modules for different motion modes; and/or
separate modules for different uses of the device (e.g., group, home or clinic).
Daily Life

15 As noted above, in an exemplary embodiment of the invention, a rehabilitation device

is used to help specifically rehabilitate a patient to achieve daily activities, such as opening
doors, eating at a table, reading a book, getting dressed, brushing teeth and washing dishes.

Fig. 19G shows a rehabilitation device 1980 configured for use for daily activities, in
accordance with an exemplary embodiment of the invention. A rehabilitation module 1952 is

20 mounted upside down over a table 1986 set with various eating utensils. An elbow rest 1984 is
optionally provided. In this embodiment table 1986 is attached to a frame 1988 which supports
mechanism 1952. Alternatively, frame 1988 may be wide enough to surround an existing table
or other home element.

In use, a hand of the patient is strapped to a movable tip 1982 of device 1980 and the

25 user attempts to or is guided through a daily activity such as picking up a fork. Optionally, a
glove with force-feedback is used to selectively rehabilitate individual fingers. Such gloves are
known in the art.

In an exemplary embodiment of the invention, device 1980 is used for one or more of
training a patient to do activities related to daily life, testing the patient's current ability to do
30 such activities and/or monitoring a patient's ability. Optionally, such testing and/or monitoring
are used by insurance companies to decide on compensation or assistance required. Such
testing can be repeated over a period of time so that attempts to cheat may be detected by
sudden spikes in ability.

WO 2005/074373 PCT/IL2005/000142

It is noted that a very important goal for rehabilitation is quality of life, which is
optionally addressed and/or determined by training and testing the ability to perform various
daily activities.

In an exemplary embodiment of the invention, specific attachments are provided for
5 daily activities training. In one example, a spillage indicating cup is provided, which includes
an inclination sensor. In another example, a whiteboard with ability to detect a pen position is
used in rehabilitation exercises involving writing on a wall. The detected position and/or
pressure is reported to the rehabilitation device which optionally holds, supports and/or guides
the hand of a patient.

10 In an exemplary embodiment of the invention, an implement of daily living is turned

into an attachment by providing one or more patches, for example stickers which include a
sensors, for example a position or a pressure sensors, and attaching the patch to a daily use
implement, such as hammer or a wall. The rehabilitation device optionally includes a position
determining means, for example, a wireless unit which communicates with position sensors on

15 the patches or a camera which images the patches, so that the rehabilitation device can
determine relative positions and/or orientations of the daily use objects. In some cases,
rehabilitation and/or diagnosis is carried out using the methods described herein but without
mechanical support or kinesthetic feedback. Optionally, vibration or other feedback is
provided to a patient by attaching a vibrating patch (under control of the rehabilitation device)

20 to a limb which is being rehabilitated.

US provisional application no. 60/566,079 filed on April 29, 2004, also being filed as
PCT application on same date as the present application and by the same applicant, entitled
"Fine Motor Control Rehabilitation" and having attorney docket number 414/04401, the
disclosures of which is incorporated herein by reference describes various structures useful for

25 rehabilitation of fine motor control or the combination of fine and gross-motor control.

Fig. 19H shows a device 1990 for assisting in training for activities of daily living, in
accordance with an exemplary embodiment of the invention. Rather than provide an entire
table, device 1990 includes two settable points 1992 and 1993 connected to a base 1994. A
pair of adjustable arms, for example goose-neck arms 1996 can be used to adjust their position

30 in space. In use, for example for pouring tea, set points 1992 and 1993 are positioned to
emulate a situation, for example pouring tea. In an exemplary exercise, a patient is required to
move a cup (e.g., helped by a rehabilitation device, not shown) from point 1992 to point 1993.
the trajectory is then evaluated. Set point 1993 is shown as a flat surface, on which items may

WO 2005/074373 PCT/IL2005/000142

be placed. Other structures and attachments, such as hooks, may be used. Optionally, set points
1992 and 1993 (more may be provided) include sensors, for example proximity sensors (to
detect human or rehabilitation robot), contact sensors, pressure sensors and/or position sensors.
The set points may also provide feedback, for example, lights, sound or vibration.
5 The relative positions of points 1992 and 1993 may be determined, for example, using

position sensors or cameras. Alternatively, tip 108 is used to register their position to the
rehabilitation device, by contacting points 1992 and 1993 in turn by tip 108. Optionally, a
dummy arm is mounted on the rehabilitation device to calibrate the relative expected position
of tip 108 and a set point, when the set point is actually being touched by a part of the user,
1 0 such as a finger.
Small Chuck

In an exemplary embodiment of the invention, a joint in an articulated arm is
configured to provide selective and/or directional resistance.

Fig. 20 is a cross-sectional view of such a joint between a rod 2004 and a rod 2002. A
15 chuck 2006 fits into a flaring end 2008 of rod 2004 and engages a ball 2012 attached to rod
2002. If chuck 2006 is retracted towards rod 2004, it tightens around ball 2012 and increases
the resistance thereof.

Optionally, one or more strain sensors and/or optical sensors is provided between

chuck 2006 and ball 2012, so that a direction of force being applied to joint 2000, can be
20 determined. Optionally, one or more electrically activated brake elements are provided, for

example piezoelectric elements, which can selectively modify a degree of resistance. This may

be provided instead of or additional to a retracting chuck mechanism.

Balanced Gimbal Device

Fig. 21 shows an alternative rehabilitation device 2100, in which a ball joint is not
25 used. An arm 2102, optionally extendible is optionally balanced by an optional counter- weight

2110 around an axle 2106. Counter- weight 2110 may include a motor or variable brake for

controlling extension of arm 2102.

A motor 2108 is optionally provided to rotate arm 2102 around axle 2106. A second

hinge 2112 is provided to allow rotation around an axis perpendicular to arm 2102 and axle
30 2106. Optionally, motor 2108 includes a weight so that it balances arm 2102 relative to hinge

2112. Optionally a slot 21 14 is provided in a base section 2104 of device 2100, for functioning

as plate 1020 and slot 1030 above. A similar structural arrangement may be used as well.

Optionally, a rotatable plate 2116 is provided for carrying slot 2114. A motor (not shown) is

WO 2005/074373 PCT/IL2005/000142

optionally provided for rotation around joint 21 12. Optionally, joint 21 12 is raised to have an
axis crossing the axis of axle 2106.
Alternative Gimbaled Device

Figs. 22A shows an alternative gimbaled device 2200 for use as a motion mechanism
5 in accordance with an exemplary embodiment of the invention. Fig. 22B, described below
shows a configuration of device 2200 including motors and/or brakes.

Device 2200 includes a gimbaled section 2202, an optionally removable z-axis element
2204 and an optionally replaceable handle 2206 attached thereto. A modular connector 2208,
for example as shown in Fig. 15 may be used. Optionally, a release pin 2210 is user to
10 selectively take off z-axis element 2204, for example,, for replacement or for storage.

Gimbaled section 2202 optionally includes a frame 2212 including a first hinge 2214.
Optionally, a guiding frame 2216 is attached to hinge 2214 that provides a first stationary axis
and includes a guide pathway for guiding an extension (or cam follower or pin) 2218
(described below).

15 A second stationary axis is provided by a hinge 2220 also on frame 2212. In an

exemplary embodiment of the invention, handle 2204 is optionally rigidly attached to a frame
2222 which includes extension 2218. Thus, the spherical rotation motion of handle 2204 is
translated to rotation of the two hinges around the stationary axes. Optionally, extension 2218
includes a balancing weight (not shown).

20 Fig. 22B shows device 2200 in an exemplary deployed configuration, with two braking

mechanisms 2232 and two force control mechanism 2230 attached. As can be appreciated a
practical device can be constructed with only one of resistance and force control. Force control
mechanisms 2230 are described below in greater detail.

Referring to braking mechanism 2232, in an exemplary embodiment of the invention, a

25 disc braking mechanism is used in which a disc (or part of a disc) 2240 is selectively
constrained by a friction element (not shown). A motor 2250 selectively sets the pressure
applied by the friction element on the disc. Other friction mechanisms may be provided as
well. In an exemplary embodiment of the invention, the following mechanism is used to
couple motor 2250 to disc 2240. A coupling 2248 converts rotational motion of motor 2250

30 into axial motion of a rod 2247. Optionally, rod 2247 is spring-loaded so that absent power to
motor 2250, the pin moves to a locked or an unlocked position, where the friction on disc 2240
is maximal or minimal (depending on the implementation). A rest 2246 is thereby selectively
lifted or pushed down by rod 2247. The friction element, while not shown, is coupled to a

WO 2005/074373 PCT/IL2005/000142

rotatable element 2242 that converts rotation thereof to motion of the friction element towards
or away from disc 2240. Optionally, element 2242 is a screw. Element 2242 includes an trans-
axial lever 2244 which is engaged by rest 2246 and thereby rotates element 2242 when rest
2246 is moved. Rotatable element 2242 is optionally spring-loaded.
5 Other brake mechanisms can be used, for example as known in the art of brakes, for

example, electrical, fluid, magnetic and/or mechanical brakes.

In an alternative embodiment of the invention, coupling between motion in the various
axis is reduced by providing a single uni -directional brake. In an exemplary embodiment of the
invention, the brake comprises a spherical segment which is selectively pressed against pin
10 2218.

Also shown in Fig. 22B are various optional sensors. A sensor 2234 is coupled to the
axis of hinge 2220 and report when handle 2204 is rotated to its limit(s). A sensor 2236 reports
when the handle is in a reference (or home) position. A sensor 2238, for example a rotatary
potentiometer or encoder reports on the angle of rotation of hinge 2220. Similar sensors may

15 be used for the hinge 2214.

In some embodiments of the invention, the brake mechanism is used for one or more of
providing safety by stopping motion, providing programmable resistance (even in a system
without active motion of the device) and/or balancing (e.g., by providing friction when needed
to counteract external forces). Optionally, the braking action in the two modules 2232 is

20 coupled to provide for uniform braking behavior independent of whether the motion of handle
2204 is along one of the stationary axes or not.
Cantilcvered Gimbaled Mechanism

Fig. 23 shows a cantilevered gimbaled mechanism 2300 in accordance with an
exemplary embodiment of the invention. A frame 2302 is coupled (rigidly or not, as will be

25 described in Fig. 25) to a handle (not shown) which is optionally attachable to a drive system
2304 (e.g., for selectable extension and resistance to axial motion of the handle). Frame 2302
is rotatably coupled to a frame 2306. In an exemplary embodiment of the invention, relative
rotation between frames 2302 and 2306 is provided by a motor 2316. In an exemplary
embodiment of the invention, motor 2316 couples the frames using a worm gear 2314 and

30 pinion 2312. Other connections methods may be provided. Optionally, the worm gear has a
lead angle small enough to prevent motion of the handle from back-driving the motor. Possibly
a worm gear is cheaper, quieter and/or allows a lower cost motor to be used, as compared to
using a precise motor and/or gear-box.

WO 2005/074373 PCT/IL2005/000142

Frame 2306 is optionally coupled to a base bracket 2307 using a similar mechanism, of
which only pinion 2308 and worm 2310 are shown.

Optionally, braking is provided as described in the previous embodiment.
Force control mechanism
5 Fig. 24A shows a force and drive control mechanism 2400, in accordance with an

exemplary embodiment of the invention. As shown, mechanism 2400 includes a drive section
and a force feedback section. One or both of these sections may be omitted in some
embodiments.

Referring first to the drive section, an axle (not shown) of hinge 2220 or 2214 is
10 coupled to an inner pinion section 2402 of a pinion 2404, for example via a gear section
formed on the axle. Optionally, other attachment methods, for example direct attachment, are
used. Pinion 2404 is rotated by a worm gear 2406 which turns on an axis 2407. In an
exemplary embodiment of the invention, power is provided by a motor 2414 via a set of two
pulleys 2408 and 2410 connected by a belt 2412. Other power trains may be used as well.
1 5 Referring to the force feedback section, in an exemplary embodiment of the invention,

worm gear 2406 has a lead angle small enough so that it cannot be back-driven by pinion
2404. Instead, force (e.g., from the handle) which counteracts the force applied by motor 2414
will cause worm gear 2406 to move axially along axis 2407. Optionally, one or both of a
viscous braking mechanism and a resilient resistance mechanism are provided to counteract
20 this force. Various combinations of settings may be provided, for example resulting in what is
shown in Fig. 3B.

Axial movement of worm gear 2406 results in displacement of one of the two levers
marked 2422 (the figure shows a mirror-imaged mechanism). Viscous cushioning is optionally
provided by a cushion 2440 resisting motion of lever 2422. Cushion 2440 is optionally

25 adjustable, for example by hand or by the rehabilitation device. A linear potentiometer or other
position sensor, are optionally used to detect the offset of worm gear 2406.

In an exemplary embodiment of the invention, a spring 2420 resists the motion of lever
2422. Optionally, spring 2420 can be selectably preloaded by a motor 2424. In the embodiment
shown, a set of pulleys 2426 and 2430 and a belt 2428 cause the rotation of a threaded shaft

30 2432. In an exemplary embodiment of the invention, a nut 2434 (or other mechanism) rides on
the screw and converts its rotation into preload of spring 2420. Optionally, shaft 2432 is
threaded in opposite directions on its two ends. It should be appreciated that separate
preloading for each of the two springs 2420 may be provided, for example if an asymmetric

WO 2005/074373 PCT/IL2005/000142

force resistance is desired, or to counter-balance for gravity. Optionally, manual adjustment of
preloading is provided by a nut 2438, possibly used for initial calibration and setting.

Optionally, a pin 2436 is provided to limit the axial extent of motion of worm gear
2406. It should be noted that if the preload is above zero, axial motion of worm gear 2406 will
5 not occur until this force is overcome. This corresponds to F m i n in Fig. 3B. Optionally, the

force mechanism is set up so that there is more resistance to extending motion (away from the
body) than to motion towards the body.

Other mechanical structures can be provided as well, for example, springs 2420 can sit
on axis 2407. In another example, instead of motor 2424 and the associated pre-load setting
10 mechanism can be replaced by a single spring coupled between the two levers 2422.

This structure can provide various modes of operation for example:

a) User passive mode. In this mode, motor 2414 drives worm gear 2406 and worm gear
2406 rotates pinion gear 2404 that is connect to the handle.

b) Free user mode. In this mode, a user moves the handle in any user determined
15 direction and the system follows the user. In this embodiment, mechanism 2400 acts as a

mechanical diode is used to decouple the user motion from the motor. As the user exerts force
on the robot arm, worm gear 2406 moves axially as described above. This linear motion is
measured and can be used as input to a controller. The amount of force felt by the user is
generally determined by the preload of spring 2420. The preload can be set or as in this case be
20 controlled by the motorized preload motor.

In the free user mode the controller receives the input from the linear potentiometer and
instructs motor 2424 to follow in the same direction. This causes the user to a predetermined
force counteracting his desired motion.

c) Restricted mode (force field). An additional use for the spring motor combination is
25 to create a track where the counteracting force is minimal but any deviation from the track will

result in higher spring displacement and thus a force opposite the deviation (e.g., as shown in
Fig. 3A). Optionally, this mode is activated for a particular speed, thereby setting up an
isokinetic exercise.

d) Initiated Mode. A user starts a motion in a certain direction, which will be sensed as
30 displacement of worm gear 2406. This motion can then be carried to completion by the

rehabilitation device. Optionally, the motion will be completed only if the initiated move was
in a predetermined direction.

e) Assist mode. When a motion is in progress, spring 2420 is preloaded in a fashion

WO 2005/074373 PCT/IL2005/000142

which pushes the handle in the direction of the motion (e.g., positive feedback). This may be a
continuous force or it may be provided in pulses.

f) Static. Optionally, the force mechanism is used to require a patient to apply a force at
a point in space without substantial movement of the handle. The force can be measured and/or
5 controlled on the fly. It should be noted that a spring mechanism can generally provide more
realistic small motions in response to force than a friction mechanism or direct robotic motion
using motors.

A potential advantage of the spring-motor combination is that velocity and/or range
limitations on motion can be provided. Another potential advantage is that gradual (e.g.,
1 0 resilient) stopping can be provided, even in an emergency stop. Another potential advantage is
that the viscous damping can provide a dynamic feeling.

Fig. 24B is a flowchart 2460 of the operation of mechanism 2400 when two such
mechanisms are attached to the device of Fig. 22B, in a free-hand mode, in accordance with an
exemplary embodiment of the invention. A similar process may be used for implementation
1 5 with force control in three axes.

Flowchart 2460 describes how the magnitude and direction of force applied by a user is
measured and then used to guide the motion of the handle. Acts 2462 through 2476 are
described only for Phi, but are carried out for all axes (e.g., Theta), as well.

At 2462, measurement of the Phi offset is acquired.
20 At 2464 optional filtering is applied, for example low pass filtering which smoothes the

signal and/or removes noise.

At 2466, a scaling operation is optionally performed, for example to match calibration
and control parameters.

At 2468, a noise gate is optionally applies where signals below a threshold are
25 converted to zero.

At 2470, the magnitude and/or direction of the change in position are optionally
extracted.

At 2472, a position command is optionally generated using a gain factor.
At 2474, the position command is optionally clamped to be at least a minimal value,
30 for example, to overcome friction and/or noise levels.

At 2476, an absolute position command is optionally generated.

At 2478, the velocities of Phi and Theta axes are calculated. Optionally, acceleration is
calculated as well.

WO 2005/074373 PCT/IL2005/000142

At 2480, a composite vector of correction is found. Optionally, the composite vector is
a maximum of phi and theta rather than a vector combination, this may serve to stabilize the
system and/or prevent mechanical problems.

At 2482, a gain smaller than 1 is optionally applied, possibly increasing the stability.
5 At 2484, the angle of the velocity vector is optionally calculated.

At 2486, the components for Phi and Theta velocity are calculated.

At 2488, a command for the motive source (e.g., motors) is generated.
Coupled Force Control Mechanism

Fig. 25 shows an alternative force control mechanism 2500 in which Phi and Theta
10 axes are coupled using a single spring mechanism. A handle 2502 is moved using axes not
shown. In one example, mechanism 2500 comprises an inner mechanism of the embodiment
described in Fig. 23 (where external Phi and Theta axes are shown).

An axis 2504 (and a matching orthogonal axis, not shown) comprise inner Phi and
Theta axes which handle 2502 rotates around a small amount when force control is applied. A
15 bottom part 2506 contacts a plate 2508. The small amount of rotation causes plate 2508 to be
depressed by part 2506 (other shapes may be provided, but part 2506 is optionally rounded at
its circumference). This depression is resisted by one or more springs 2510, for example four
springs. The pre-load of the springs may be set using a motor 2522 which using a driver train
comprising pulleys 2520 and 2516 and a belt 2518 can rotate a screw 2514 which compresses
20 springs 2510 by lifting a base 2512. Alternatively or additionally, manual pre-loading may be
practiced

Optionally, linear motion of plate 2508 is ensured using a bushing 2524 or other means
as known in the art. A mechanical stop may be provided to the relative motion of cap 2508 and
base 2512, so that sufficient preload of springs 2510 prevents any mechanical motion.
25 The rounding of the edges of part 2506 may be calculated to ensure a linear

relationship between angle of rotation and displacement.

The axes of inner rotation may be congruent with the axes of external rotation,
however, this is not required. For example, the axes may not be co-planar and/or the axes may
not be parallel.

30 Various measurement means may be provided, for example, a linear potentiometer

measuring spring displacement and/or rotary potentiometers measuring Phi and Theta rotation.
Measured values may be used with the flowchart of fig. 24B.

Optionally, spring 2510 is used to also provide compliance in the Z-direction. In one

WO 2005/074373 PCT/IL2005/000142

example, when handle 2502 is depressed, spring 2510 provides resistance. The hinge at axis
2504 is optionally placed in a slot is that z-axial motion of the hinge is possible.
Z-axis Motion Mechanism

Fig. 26A and 26B shows a z-axis motion and force response mechanism 2600, in
5 accordance with an exemplary embodiment of the invention. The mechanism comprises a three
part telescoping rod comprising a central portion 2604, a top portion 2608 and a bottom
portion 2606. An external motor (e.g. 2304 from Fig. 23) couples to a coupling 2602 and
thereby rotates a rod 2609. The use of an external motor optionally helps modularity as a z-
axis mechanism can be made lower cost and interchangeable with other z-axis mechanisms. A

10 coupling 2610, for example a nut converts the rotary motion into axial motion of central
portion 2604. The telescoping of portions 2604, 2606 and 2608 is optionally guided by a pair
of linear bearings, 2614 for portion 2608 and 2612 for portion 2606. The linear bearings lie in
cannels 2613 and 261 1, respectively.

In an exemplary embodiment of the invention, a combined rack and pinion and timing

15 belt mechanism is used to synchronize the extension of portions 2606 and 2608, as follows.
Each of the channels 2611 and 2613 also includes a rack defined thereon and portion 2604
includes two pinions 2616 and 2618, one on either end. When portion 2604 extends, rack 261 1
causes pinion 2616 to rotate. A timing belt 2620 which is connected between pinions 2616 and
2618 (on co-axially coupled belt pulleys of same effective diameter) causes pinion 2618 to

20 rotate in synchronization. Pinion 2618 then moves rack 2613, causing telescoping of portion
2608.

In an exemplary embodiment of the invention, telescoping allows the z-axis
mechanism to be compact and assist in portability. Also, it allows motions near to the center of
rotation of the motion mechanism. In an exemplary embodiment of the invention, telescoping

25 allows a range of 2:1 or close to 3:1 of z-axis length. Additional telescoping potions can be
provided for a greater extension ratio.

Referring to the upper part of the z-axis mechanism, an exchangeable handle 2630 is
shown. Axial motion of handle 2630 is optionally shown by motion of a linear measurement
potentiometer 2638. Optionally, handle 2630 is attached using a quick connect mechanism.

30 In an exemplary embodiment of the invention, a spring 2632 provides resilient

resistance to axial motion of handle 2630, for example using the logic as described above in
Fig. 24.

Referring to Fig. 26B, spring 2632 is a spiral spring, whose resistance can be changed

WO 2005/074373 PCT/IL2005/000142

by changing its effective length, for example by moving a sliding stop 2636 which determines
a length of the leaves of spring 2632. This sliding stop is optionally moved manually, for
example by rotating a housing 2634. Alternatively, an internal motor may be provided. This
change in leaf length is generally comparable to a change in preload. Minimal force setting
5 may be provided by actually preloading spring 2636, for example by axial motion thereof, or
by providing another spring to resist axial motion. Preload may also be achieved by rotating
spring 2632 itself, thereby tensing the spring.

The range of motion of the force control mechanisms can be, for example, 3 cm, 5 cm,
10 cm, 15 cm, 20 cm or intermediate, smaller or greater ranges, depending on the
1 0 implementation.

It should be noted that in some embodiments of the invention the use of gear-reduction
ratios allows lower power and/or lower cost motors to be used.

It should be noted that force in the Z-axis can be transferred using a flexible or a bent
coupling. Thus, for example, the z-axis element can be a 90 degree elbow in which only the far
15 portion extends. Alternatively or additionally, goose-neck like mechanism is used to define
shape in space for the z-axis element.
Games

Various games have been mentioned. In an exemplary embodiment of the invention,
one or more of the following game-types is provided: role playing games (adventure and D&D
20 games), kinetic games (shoot-em-up), board games and simulation games (e.g., soccer and
tennis).

Games may be played, for example, one-on-one, against a human opponent or against a
machine opponents.

In an exemplary embodiment of the invention, device 1 00 serves as an input device, for
25 example replacing a joystick. Alternatively or additionally, device 100 is used as a VR input
device, for example to read limb positions. Alternatively or additionally, specialized input
modes may be defined, for example, spatial positions of arm 102 may be mapped to virtual
positions on the screen or in the game world, or to velocities and/or accelerations thereof.
Gestures may be defined for various controls, for example, "fire", "lift" and "put" commands
30 may each have an associated gesture.

In an exemplary embodiment of the invention, child games are provided, for example
for encouraging paretic or CP children to avoid neglecting body parts. Device 100 may also be
used as a social focal point for preventing the paretic child from becoming an outcast.

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In an exemplary embodiment of the invention, a game is fitted to the ability of the
patient, for example, limiting the ROM required, providing enhancement of patient motion,
changing the game speed and changing the visual field which needs to be attended.

In an exemplary embodiment of the invention, the game is selected to match a
motivation level of the patient, for example, a simple game selected for low-motivation
patients.
Safety

In an exemplary embodiment of the invention, one or more safety features are provided
to prevent injury to a patient. For example, one or more of the following safety mechanism
may be used:

a) Dead man switch. If a patient releases this switch (or touches a suitable button)
movement of device 100 is frozen and/or all forces and resistance brought to zero. Other "safe
harbor" configurations can be defined instead.

b) Tearing pin. A pin may be used to attach tip 1008 (or other attachment) to arm 1002.
If a certain threshold force is exceeded, the pin tears and the attachment is released from the
arm. Different pins with different tearing thresholds may be selected for different situations.
Optionally a wire can be attached to the pin for feedback. Optionally the pin comprises two
magnetically attracted materials, with the degree of attraction optionally set by electrical
current.

c) Locking. Arm 1002 may have an initial locking condition, to allow a patient to lean

on it.

d) Voice activation. Voice activation and/or deactivation may be provided, to allow a
patient to shout the system to a stop.

e) Analysis. Optionally, the actual movements and/or forces applied by a patient are
analyzed to determine if a threshold is being approached or if the patient is experiencing undue
stress.

f) Resiliency. The force control mechanism with a spring prevents sudden stops from
suddenly stopping the patient. Instead, the spring allows some compliance and a more gradual
stop.

g) Force-measured. If the force mechanism determines a force and/or spatial
divergence above a threshold, the motion can be stopped and optionally moved opposite to the
direction of force application.

Balance Training

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In an exemplary embodiment of the invention, a rehabilitation module is used for
balance training. In one example, a seat is attached to tip 1008 and a patient sits on the seat. A
non-rotating plate 1020 with a slot sets the direction in which the seat is allowed to roll and the
resistance level sets the difficulty. Optionally, a handle bar is provided. Alternatively or
5 additionally, a foot rest and/or pedals are provided for the feet. Alternatively one or more
rehabilitation modules for the arms are provided. In this manner, various daily and sports
activities can be simulated and trained for. Optionally, a virtual reality type display or a
television display are provided to enhance the sense of reality. Such a virtual reality display
may be provided in other embodiments of the invention, for example to show feedback, to

10 show instructions or to make the activity more interesting.

US provisional application no. 60/633,442 filed on December 7, 2004, also being filed
as PCT application on same date as the present application and by the same applicant, entitled
"Methods and Apparatuses for Rehabilitation Exercise and Training" and having attorney
docket number 414/04388, the disclosures of which are incorporated herein by reference,

15 describes training of balance, for example, using such a chair. Optionally, a full body system is
used to train multiple body parts associated with balance simultaneously, for example, torso,
arms and/or legs.

In an exemplary embodiment of the invention, device 1 00 is used to train balance while
standing. For example, a patient performing a reaching exercise to arm 102, when tip 108 is at
20 various spatial positions; some positions requiring only arm extending and some positions
requiring torso bending.

Multi-modal therapy and coordination training

In an exemplary embodiment of the invention, device 100 can be used for providing
rehabilitation in modes other than motor. In one example, the displays (audio and/or visual) are

25 used to perform visual and/or auditory rehabilitation. Thus, a single device can be used for
multiple rehabilitation types (e.g., at home) and serve as a single point of contact both for the
patient and for the therapist. If multiple therapists exist, the device can serve to coordinate
between the various therapies and/or track general parameters, such as general progress,
motivation and/or cognitive level. In an exemplary embodiment of the invention, device 100

30 selectively applies an exercise in one of several modalities, for example, for load balancing
and/or for interest.

In an exemplary embodiment of the invention, device 100 is used to rehabilitate the
coordination between modalities and/or using the rehabilitation of one modality to help

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rehabilitate other modalities. One example is eye-hand coordination, where a patient is shown
a target on a screen and the aim is to move tip 108 to tack it. Another example is timing where
a patient needs to provide a command at a certain timing, possibly in an auditory modality.
Another example is spatial planning, where a patient is provided with verbal instructions of
5 gradually increasing complexity with regard to spatial motions.

In an exemplary embodiment of the invention, progressively more complex visual
instructions, motor acts and feedback (visual or not) are provided to the patient. Similarly,
progressively more complex audio, kinesthetic, haptic, and smell (using scent release
attachments) feedback and/or instructions are provided.

10 In a particular example, speech recognition is rehabilitated in concert with motion for

example requiring speech to be understood fast enough to perform the motion in time, or
respond to verbal instructions. A user may be required to provide speech utterances which
match his motions. A speech recognition module may be provided.

In another example, visual stimuli is made more complex as visual rehabilitation

15 progresses, for example, starting with a light, then a light at a position, then a speed of
blinking, then text which must be read, all of which are used to prompt motor action or serve
as feedback (e.g., for progressively complex motor tasks: moving arm, moving to a direction,
moving to a particular area).

A particular advantage of some embodiments of device 100 is mechanical feedback

20 and support is provided to the patient. In some embodiments, some of the methods described
herein for motor rehabilitation (and which may find special utility therefor) are used for non-
motor rehabilitation, for example, measuring motivation, remote rehabilitation, group activities
and support by a computer of user activities (for example for group participation).
Other Devices

25 Various designs for robots and positioning devices (e.g., hexapods) are known in the

art. It should be appreciated that various ones of the statements described herein may be
adapted for such robots and/or positioning devices, in accordance with exemplary
embodiments of the invention. Alternatively or additionally, software may be provided for
such robots and devices for carrying out various ones of the methods described herein, all in

30 accordance with exemplary embodiments of the invention.

US provisional application no. 60/604,615 filed on August 25, 2004, the disclosure of
which is incorporated herein by reference, describes taking the effects of brain plasticity into
account. The methods described herein may use EEG or fMRI as an input for deciding, for

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example, on feedback or type of device mode to use.

U.S. Provisional Application 60/566,078 filed on April 29, 2004, also being filed as
PCT application on same date as the present application and by the same applicant, entitled
"Neuromuscular Stimulation" and having attorney docket number 414/04400, the disclosures
5 of both applications are incorporated herein by reference, describe stimulating a paretic limb
while moving the limb or otherwise supporting the motion of the limb. EMG measurements,
for example of healthy limbs are optionally used as part of the teaching of the present
application for deciding on stimulation and/or supported motion of a paretic limb.

It should be noted that the rehabilitation devices described herein are optionally usable
10 not only at a home but also at care centers, such as old age homes, hospitals and rehabilitation
centers.

It will be appreciated that the above described methods of rehabilitation may be varied
in many ways, including, omitting or adding steps, changing the order of steps and the types of
devices used. In addition, a multiplicity of various features, both of method and of devices

15 have been described. In some embodiments mainly methods are described, however, also
apparatus adapted for performing the methods are considered to be within the scope of the
invention. It should be appreciated that different features may be combined in different ways.
In particular, not all the features shown above in a particular embodiment are necessary in
every similar embodiment of the invention. Further, combinations of the above features are

20 also considered to be within the scope of some embodiments of the invention. Also within the
scope of the invention are kits which include sets of a device, one or more tearing pins, one or
more attachments and/or software. Also, within the scope is hardware, software and computer
readable-media including such software which is used for carrying out and/or guiding the steps
described herein, such as control of arm position and providing feedback. Section headings are

25 provided for assistance in navigation and should not be considered as necessarily limiting the
contents of the section. When used in the following claims, the terms "comprises", "includes",
"have" and their conjugates mean "including but not limited to". It should also be noted that
the device is suitable for both males and female, with male pronouns being used for
convenience.

30 It will be appreciated by a person skilled in the art that the present invention is not

limited by what has thus far been described. Rather, the scope of the present invention is
limited only by the following claims.

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CLAIMS

PCT/IL2005/000142

1 . A method of rehabilitation using an actuator type that includes a movement mechanism
capable of applying a force that interacts with a motion of a patient's limb in a volume of at

5 least 30 cm in diameter, in at least three degrees of freedom of motion of the actuator and
capable of preventing substantial motion in any point in any direction in said volume,
comprising:

wherein said first exercising and said second exercising utilize a same movement
1 5 mechanism design for moving the actuators.

2. A method according to claim 1, wherein said first and said second exercising are
performed using a same rehabilitation apparatus.

20 3. A method according to claim 1, wherein said motion mechanism is motorized.

4. A method according to claim 3, wherein said motion and said force are controlled by a
controller.

25 5. A method according to claim 3, wherein said motion mechanism is capable of applying
a force of at least 1 0 Kg to a tip of said actuator.

6. A method according to claim 3, wherein said motion mechanism is capable of applying
a force of different magnitudes in different directions of motion said actuator.

7. A method according to claim 1, wherein said motion mechanism is adapted to apply
selective resistance to motion of said actuator.

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8. A method according to claim 1, wherein said actuator is adapted to interact with said
motion in a plurality of modes including at least causing said motion, guiding said motion and
recoding said motion.

5 9. A method according to claim 8, wherein said first and said second exercising use
different motion interaction modes.

10. A method according to claim 1, wherein at least one of said first and said second
exercising are performed in water.

11. A method according to claim 1, wherein said first and said second exercising are
performed on a same limb.

12. A method according to claim 1, wherein said first and said second exercising are
1 5 different exercises.

13. A method according to claim 1, comprising keeping track of progress of said patient
including said first and said second exercising, in a same controller coupled with said second
actuator.

14. A method according to claim 1, wherein said actuator is rigid.

15. A method of rehabilitation using an actuator that includes a movement mechanism
capable of applying a force that interacts with a motion of a patient's limb in a volume of at

25 least 30 cm in diameter, in at least three degrees of freedom of motion of the actuator and
capable of preventing substantial motion in any point in any direction in said volume,
comprising:

exercising a first organ type of a patient using said actuator; and
exercising a second organ type of the patient using said actuator.

16. A method according to claim 15, comprising replacing an attachment to said patient of
said rehabilitation device between said exercising.

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17. A method according to claim 15, the actuator comprises a controller which controls
said interaction.

18. A method according to claim 17, wherein said controller is programmed with a
5 plurality of different exercises for different limbs

19. A method according to claim 15, comprising adjusting at least one of a spatial position
and orientation of said actuator relative to said patient, between said exercises.

10 20. A rehabilitation kit, comprising:

a plurality of attachments modularly exchangeable for said tip, at least two of which are
adapted to fit different organs.

21. A kit according to claim 20, wherein at least one of said attachments is powered via
20 said actuator.

22. A kit according to claim 20, wherein at least one of said attachments is capable of
rotation in three axes of rotations.

25 23. A device for rehabilitation, comprising:

a motorized actuator adapted to support a movement by a person by at least one of
resisting motion, guiding motion and causing motion; and
a controller configured to control said actuator,

wherein, said controller is programmed to provide rehabilitation exercising for patient's
30 switchable between a plurality of modes in which one or more or motivation, cognitive ability
and motor ability is either high or low.

24. A device according to claim 23, wherein said controller is configured to provide

101

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instructions in a selectable one of at least three information presentation modes and complexity
levels.

25. A device according to claim 23 , wherein said controller is configured to provide
5 support for motor activity of said patient in a selectable one of at least three levels of
assistance.

26. A device according to claim 23, wherein said controller is configured to provide
incentive feedback to said patient in a selectable one of at least three levels of incentive.

27. A method of rehabilitation using an actuator that includes a movement mechanism
capable of applying a force that interacts with a motion of a patient's limb in a volume of at
least 30 cm in diameter, in at least three degrees of freedom of motion of the actuator and
capable of preventing substantial motion in any point in any direction in said volume,

15 comprising:

coupling said actuator to a person in a home setting;

performing a daily activity by said person, wherein said actuator interacts with said
activity to enhance rehabilitation.

20 28. A method according to claim 27, wherein said daily activity is outdoors

29. A method according to claim 27, wherein said actuator interacts using a stored
rehabilitation plan.

25 30. A method according to claim 27, wherein said actuator reports to a remote location on
a progress of rehabilitation.

31. A method according to claim 27, wherein said actuator prevents unsafe motions by said
patient.

32. A method according to claim 27, comprising first practicing said daily activity at a
rehabilitation clinic.

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33. A method of rehabilitation, comprising:
rehabilitating a first patient on a first rehabilitation device;
rehabilitating a second patient on a second rehabilitation device; and

34. A method according to claim 33, wherein said patients play a game together using said
devices for input and output.

35. A method according to claim 34, wherein said patients play against each other.

36. A method according to claim 34, wherein said first rehabilitation device provides a
different support fro said first patient than said second device supplies for said second patient,

1 5 to compensate for differences in ability between the two patients.

37. A method according to claim 33, wherein said information is passed in real-time.

38. A method according to claim 33, wherein said information is passed using a wireless
20 connection.

39. A method according to claim 33, comprising monitoring said first and said second
patients by a remote therapist.

25 40. A method according to claim 33, comprising remotely connecting into a therapy group
by said patients.

41 . A method according to claim 33, wherein said two devices are in a same room.

30 42. A rehabilitation system configuration, comprising:

A first rehabilitation device; and

A second rehabilitation device linked by a wireless data link with said first
rehabilitation device such that the two rehabilitation devices can act in synchrony.

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43. A method of cooperative rehabilitation, comprising:

providing a first actuator that includes a movement mechanism capable of applying a
force that interacts with a motion of a patient's limb in a volume of at least 30 cm in diameter,
5 in at least three degrees of freedom of motion of the actuator and capable of preventing
substantial motion in any point in any direction in said volume;

engaging said first and said second actuators by a patient and by a non-therapist,
respectively; and

rehabilitating said patient using said first actuator and said non-therapist.

15 44. A method according to claim 43, wherein said non-therapist is a blood relative.

45. A method according to claim 43, comprising guiding said non-therapist and said
patient by instructions by a controller.

20 46. A method according to claim 43, wherein said non-therapist is under an age of 1 8.

47. A method according to claim 43, wherein said non-therapist is under an age of 10.

48. A method according to claim 43, wherein said providing is at a home of said non-
25 therapist.

49. A method according to claim 43, wherein said non-therapist has fewer than 50 hours
experience in physical therapy.

30 50. A method according to claim 43, wherein said non-therapist has fewer than 10 hours
experience in physical therapy.

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310

FIG.3A

Fmax

Fmin

DELTA
POSITION

FIG.3B

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400

4/40

TURN ON DEVICE
(OPTIONAL)

DOWNLOAD INSTRUCTIONS
(OPTIONAL)

SELECT ACTIVITY

START POSITION
(OPTIONAL)

WARMUP
(OPTIONAL)

TEST
(OPTIONAL)

CALIBRATE OR RESELECT
(OPTIONAL)

FEEDBACK
(OPTIONAL)

MORE
(OPTIONAL)

402

404

406

408

410

412

414

416

418

420

422

FIG.4A

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430

432

TEST PATIENT

434

ANALYZE NEEDS

43 6_-

DEVISE PLAN

438__

TRACK PROGRESS

440__

MODIFY PLAN

442__

REPEAT TESTING

TRAINING PLAN

446__

LONG TERM
MONITOR

448

IDENTIFY
NEW NEEDS

FIG.4B

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FIG.9B

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1008

1014

1002

1004

FIG. 10

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FIG.ll

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FIG. 12

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1302

FIG.13A

1340

1354^

FIG.13B

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1022

1020

1402

1022

FIG.14A

FIG.14B

FIG.14C

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1560

1562

1564

FIG.15D

1572

1570

1574

1578

FIG.15E

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FIG.15F

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1605.

FIG.16A

FIG.16B

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FIG.16C

FIG.16D

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1700

1706

1704

FIG.17A

1722

1721

1710

1714

1712

1714

1716

FIG.17B

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FIG.17D

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FIG.19G

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-2000

2010

2006

2008

2012

2004-^

FIG.20

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FIG.21

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2200

2210

2220

2222

2206

2208

2204

2218 ^2216

2212

2202

2214

FIG.22A

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FIG.22B

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2300

FIG.23

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/ \ ^

( ^GET PHI FQRCELL SENSOR J L^

2462

LOW PASS FILTER SMOOTH SIGNAL AND

REMOVE NOISE

POSITION = ANALOG INPUT* UNITS_SCALE

PERFORM "NOISE GATE."
IF VALUE < THRESHOLD THEN VALUE = 0

DELTA POSITION = ABS (POSITION)
SIGNPOS ~ SIGN (POSITION)

POSITION COMMAND = GAIN*DELTA POSITION

IF POSITION COMMAND < THRESHOLD THEN
POSITION COMMAND = THRESHOLD

ABSOLUTE POSITION COMMAND = ABSOLUTE
POSITION COMMAND + POSITION COMMAND

CALCULATE PHI AND THETA VELOCITY

FIND MAXIMUM BETWEEN PHI AND THETA
FORCELL SIGNAL VELOCITY

STABILIZATION AND CONTROL GAIN

CALCULATE VELOCITY VECTOR ANGLE FROM
DELTA POSITION IN PHI AND THETA

CALCULATE PHI AND THETA VELOCITY
COMPONENTS FROM MAX
VELOCITY AND VECTOR ANGLE

OUTPUT ABSOLUTE POSITION COMMAND AND
AXIS VELOCITY TO THE DRIVE

END

FIG.24B

■2460

2464

2466

2468

2470

2472

2474

2476

2478

2480

2482

2484

2486

2488

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2630

FIG.26A

(12) INTERNATIONAL APPLICATION PUBLISHED UNDER THE PATENT COOPERATION TREATY (PCT)

(19) World Intellectual Property Organization

International Bureau

(43) International Publication Date
18 August 2005 (18.08.2005)

PCT

(10) International Publication Number

WO 2005/074373 A3

A61H 1/00

(51) International Patent Classification :

(21) International Application Number:

PCT/IL2005/000142

(22) International Filing Date: 4 February 2005 (04.02.2005)

(25) Filing Language:

(26) Publication Language:

English
English

(30) Priority Data:

60/542,022
60/566,078
60/566,079
60/604,615
60/633,428
60/633,442
60/633,429

5 February
29 April
29 April
25 August
7 December
7 December
7 December

2004
2004
2004
2004
2004
2004
2004

(05.02.
(29.04.
(29.04,
(25.08.
(07.12.
(07.12.
(07.12.

2004)
2004)
2004)
2004)
2004)
2004)
2004)

US
US

us
us
us
us
us

(71) Applicant (for all designated States except US): MO-
TORIKA INC. [GB/GB]; Nerine Chambers, P.O. Box
905, Road Town, Tortola (VG).

(72) Inventors; and

(75) Inventors/Applicants (for US only): EINAV, Order
[IL/IL]; 42875 Kfar Monash (IL). EINAV, Haim [IL/IL];
28 SHLUSH STREET, 65149 TEL-AVIV (IL). ROUSSO,
Benny [IL/IL]; 12 HENRY BERGSON STREET, 75801
RISHON LEZION (IL). SHABANOV, Doron [IL/IL];
34 HADKALIM BOULEVARD, 44862 ZUR IGAL
(IL). KATZIR, Eran [IL/IL]; 12 AMNON VETAMAR
STREET, 48580 ROSH HA'AYIN (IL). BINYAMINI,
Gad [IL/IL]; 45870 MOSHAV HAGOR (IL).

(74) Agents: FENSTER, Paul et al; FENSTER & COM-
PANY, INTELLECTUAL PROPERTY LTD., P. O. BOX
10256, 49002 PETACH TIKVA (IL).

(81) Designated States (unless otherwise indicated, for every
kind of national protection available): AE, AG, AL, AM,
AT, AU, AZ, BA, BB, BG, BR, BW, BY, BZ, CA, CH, CN,
CO, CR, CU, CZ, DE, DK, DM, DZ, EC, EE, EG, ES, FT,
GB, GD, GE, GH, GM, HR, HU, ID, IL, IN, IS, JP, KE,
KG, KP, KR, KZ, LC, LK, LR, LS, LT,LU, LV,MA, MD,
MG, MK, MN, MW, MX, MZ, NA, NI, NO, NZ, OM, PG,

/ Continued on next page ]

(54) Title: METHODS AND APPARATUS FOR REHABILITATION AND TRAINING

1980

1988

1982

U y 1984

1986

(57) Abstract: A method of rehabilitation using an ac-
tuator type that includes a movement mechanism capable
of applying a force that interacts with a motion of a pa-
tient's limb in a volume of at least 30 cm in diameter, in
at least three degrees of freedom of motion of the actu-
ator and capable of preventing substantial motion in any
point in any direction in the volume, including exercising
a patient at a first place of rehabilitation selected from a
bed, a wheel-chair, a clinic and a home, using an actuator
of said actuator type which interacts with a motion of the
patient at a second place of rehabilitation selected from
a bed, a wheel-chair, a clinic and a home using a second
actuator of the actuator type which interacts with a mo-
tion of the patient; wherein the first exercising and the
second exercising utilize a same movement mechanism
design for moving the actuator.

WO 2005/074373 A3 I lllll llllllll II llllll lllll Hill Hill llll I II 111 lllll lllll lllll Hill lllll INI lllllll llll llll llll

PH, PL, PT, RO, RU, SC, SD, SE, SG, SK, SL, SM, SY,
TJ, TM, TN, TR, TT, TZ, UA, UG, US, UZ, VC, VN, YU,
ZA, ZM, ZW.

(84) Designated States (unless otherwise indicated, for every
kind of regional protection available): ARIPO (BW, GH,
GM, KE, LS, MW, MZ, NA, SD, SL, SZ, TZ, UG, ZM,
ZW), Eurasian (AM, AZ, BY, KG, KZ, MD, RU, TJ, TM),
European (AT, BE, BG, CH, CY, CZ, DE, DK, EE, ES, FI,
FR, GB, GR, HU, IE, IS, IT, LT,LU, MC, NL, PL, PT, RO,
SE, SI, SK, TR), OAPI (BF, BJ, CF, CG, CI, CM, GA, GN,
GQ, GW, ML, MR, NE, SN, TD, TG).

Published:

— with international search report

— before the expiration of the time limit for amending the
claims and to be republished in the event of receipt of
amendments

(88) Date of publication of the international search report:

8 September 2006

For two -letter codes and other abbreviations, refer to the "Guid-
ance Notes on Codes and Abbreviations "appearing at the begin-
ning of each regular issue of the PCT Gazette.

INTERNATIONAL SEARCH REPORT

International application N o

PCT/IL05/00142

A CLASSIFICATION

OF SUBJECT MATTER

IPC(7) A61H

1/00

US CL 601/5

According to International

Patent Classification (IPC) or to both national classification

and IPC

B FIELDS SEARCHED

Minimum documentation searched (classification system followed by classification symbols)

U S 601/5, 602/32-40

Documentation searched other than minimum documentation to the extent that such documents are included in the fields searched

Electronic data base consulted during the international search (name o f data base and, where practicable, search terms used)
EAST

DOCUMENTS

CONSIDERED

TO BE RELEVANT

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